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CORNELL UNIVERSITY. 




THE 
THE GIFT OF 

ROSWELL P. FLOWER 

FOR THE USE OF 

THE N. Y. STATE VETERINARY COLLEGE 
1897 

8349-1 



CORNELL UNIVERSITY LIBRARY 



924 104 225 754 




The original of tiiis book is in 
tine Cornell University Library. 

There are no known copyright restrictions in 
the United States on the use of the text. 



http://archive.org/details/cu31924104225754 



LIST OF AUTHORS 


IN 


VOL. L 


BIGGS, HERMANN M., 


M. 


D. 


i 


BILLINGS, JOHN S., M. 


D. 


LL.D.; 


CARMALT, WILLIAM H., 


M. 


D-; 


CONNER, PHINEAS S., 


M. 


D. 


; 


COUNCILMAN, WILLIAM 


T. 


M. D. ; 


DENNIS, FREDERIC S., 


M 


.D 


} 


GERSTER, A. G., M.D.; 








NANCREDE, CHARLES 


B. 


, M.D.; 


SMITH, STEPHEN, M. E 


'•; 






WARREN, J. COLLINS, 


M 


D. 


) 


WELCH, WILLIAM H., 


M. 


D. 


; 


WOOD, HORATIO C, N 


[.E 


. 





SYSTEM 



SURGERY 



EDITED BY 

FEEDEEIC S. DENNIS, M.D., 

Professor of the Principles and Practice of Surgery, Bellf.vue Hospital Medical College ; 

Visiting Surgeon to the Bellevue and St. Vincent Hospitals ; Consulting Surgeon 

to the Harlem Hospital and the Montefiore Home, New York ; President 

of the American Surgical Association; Graduate of the Royal 

College of Surgeons, London ; Member of the German 

Congress of Surgeons, Berlin, ^V i "^\ 

ASSISTED BY 

JOHN S. BILLINGS, M. P.; 

LL.D. Edin. and Harv. ; D. C. L. OxoN. ; Deputy Surgeon-general U. S. 




Vol. I. 



THE HISTORY OF SURGERY-PATHOLOGY-BACTERIOLOGY- 

INFECTIONS -ANAESTHESIA- FRACTURES AND 

DISLOCATIONS-OPERATIVE SURGERY. 



I-Ii OFUSEL Y ILL USTBA TED. 




PHILADELPHIA: 
LEA BEOTHEES & CO. 

1895. 



Entered according to Act of Congress in the year 1895, by 

LEA BROTHERS & CO., 

in the Office of the Librarian of Congress, at Washington. All rights reserved. 



3 I 



WESTCOTT & THOMSON, PRESS OF 

ELECTROTVPEHS, PHILAOA. WILLIAM J. DORNAN, PHILADA. 



PREFACE. 



This System of Surgery is intended to meet a growing want created 
by the great progress which Surgery has made during the past few 
years. It is with a view to fulfil this object that men of recognized 
authority in their respective branches have consented to contribute in 
order to present to the profession a complete review of the domain of 
modern Surgery — a domain which has so wonderfully enlarged its bound- 
aries through the achievements rendered possible by the systematic 
employment of antiseptic and aseptic methods of procedure. The task 
has been most onerous, but the labors of an eminent corps of contribu- 
tors have enabled the Editor to offer to the profession a concise and 
complete work, presenting the most advanced opinions upon the new 
problems involved in modern surgery, as well as the practical details 
which conduce to success in treatment. In accomplishing this it is 
gratifying to be able to announce that the whole has been the work 
of American surgeons, and that it may be fairly said to represent the 
most advanced condition of American Surgery. 

The Editor takes this occasion to acknowledge his obligations to the 
contributors, each one of whom is a teacher of Surgery or a director in 
some large surgical clinic or hospital, and who, for this reason, is capable 
of speaking with clinical authority from an experience based on the 
study and observation of a large number of cases. Each department 
is thus treated by an acknowledged master of the subject, who is able to 
present the most modern and advanced views in the most cogent and 
demonstrative way. 

The Editor trusts that he will be found to have succeeded in the 
endeavor to present a work of the scope and breadth that this great 
subject demands, and that an appreciative reception will be accorded to 
the results given by the contributors, who, though busy men, have con- 
sented to oifer the fruits of their labors for the benefit of the medical 
profession. 

The Editor especially desires to acknowledge, with sincere thanks, 
the great assistance accorded to him by Dr. John S. Billings, through 
whose valuable services and co-operation he has been enabled to bring 
before the profession this work in its present comprehensive and at 
the same time compact form. 

Ko. 542 Madison Avenue, New Yobk. 
March, 1S95. 

s 



CONTENTS OF VOLUME I. 



PAGE 

THE HISTORY AXD LITERATUEE OF SURGERY 17 

By Johx S. Billings, M. D., LL.D., Edinburgh and Harvard ; D. C. L. Oxon. ; 
Deputy Surgeon-general, U. S. A. 

SURGICAL PATHOLOGY, INCLUDING INFLAMMATION AND THE 
REPAIR OF WOUNDS .... . . .145 

By "William T. CouNCiLJiAisr, M. D., Professor of Pathology, Harvard Med- 
ical School, Boston. 

GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS 249 

By William H. Welch, M. D., Professor of Pathology, Johns Hopkins 

Laiiversity, Baltimore. 

\ 
SYMPTOilS, DIAGNOSIS, AND TREATMENT OF INFLAMMATION, 

ABSCESS, ULCER, AND GANGRENE '., . 335 

By Charles B. Nancrede, A. M., M. D., Professor of Surgery and of Clinical 

Surgery, Medical Department of the University of Michigan, Ann Arbor. 

SEPTICEMCA, PY.EMIA, AND POISONED WOUNDS . . 383 

By AVilliam H. Carmalt, M. D., Professor of Surgery, Department of 
Medicine, Yale University, New Haven. 

TRAUMATIC FEVER, ERYSIPELAS, AND TETANUS 415 

By J. Collins Warren, M. D., Professor of Surgery, Harvard Medical 
School, Boston. 

RABIES ; HYDROPHOBIA ; LYSSA ... ... 433 

By Hermann M. Biggs, M. D., Professor of Therapeutics and Clinical Medi- 
cine, formerly Professor of Pathology, Bellevue Hospital Medical College ; 
Visiting Physician Bellevue Hospital, New York. 

GUNSHOT WOUNDS ... . . 445 

By Phineas S. Conner, M. D., Professor of Surgery and of Clinical Surgery, 
Medical College of Ohio, Cincinnati, and also in Dartmouth Medical College, 
Hanover, N. H. 

7 



8 CONTENTS. 

PAGE 

FRACTUKES AND DISLOCATIONS , . . . . 515 

By Fkedeeio S. Dennis, M. D., Professor of the Principles and Practice of 
Surgery, Bellevue Hospital Medical College ; Surgeon to the Bellevue and 
St. Vincent Hospitals, New York. 

ANESTHESIA .... .645 

By HoEATio C. Wood, M. D., LL.D., Professor of Materia Medica, Pharmacy, 
and General Therapeutics, University of Pennsylvania, Pliiladelphia. 

THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SUBGERY . . 677 

By Aepad G. Gerster, M. D., Professor of Surgery in the New York 
Polyclinic ; Surgeon to the German and Mt. Sinai Hospitals, New York. 

OPERATIVE SURGERY . . . ... 729 

By Stephen Smith, M. D., Emeritus Professor of Clinical Surgery, University 
of the City of New York ; Visiting Surgeon to St. Vincent, and Consulting 
Surgeon to Bellevue Hospital, New York. 



THE HISTORY AND LITERATURE OF 
SURGERY. 

By JOHN S. BILLINGS, M. D. 



In this sketch of the development of Surgery during the last three 
thousand years a brief account is given, mainly in chronological order, 
of the chief discoverers, improvers, and inventors in the art, and also of 
the principal teachers of it. The original inventor may or may not have 
been a lecturer or author, and the date of the first improvement in a 
method of treatment or in the performance of a new operation was often 
long prior to that general knowledge of such improvement which is 
necessary to constitute true development. Some account is also given 
of the trade, guild, or craft associations or corporations of surgeons, and 
of their relations to education and to legislation. A few illustrations of 
the state of the art at diiferent periods, in the shape of the recommenda- 
tions of different writers with regard to methods of treatment of certain 
injuries or diseases, are presented ; but no attempt is made to trace the 
history of the growth of knowledge with regard to each particular form 
of disease or operation, this being left to the writers of monographs on 
these particular subjects. 

It requires leisure, patience, and access to a large library to make 
historical studies really interesting, and the most I can hope to accom- 
plish in this paper is to furnish to the physician who has little time, 
taste, or opportunity for consulting the original documents the means of 
ascertaining the periods and places in which the leading surgeons of the 
world have done their work. The printed literature of surgery is vast 
in quantity, and the great majority of it is obsolete and practically use- 
less : even for statistical purposes the records of operations performed 
prior to 1870 have now lost much of the value which they possessed 
at that date ; yet in many respects the old surgical monographs, col- 
lections of cases, and systems are the most definite and interesting of all 
ancient medical literature. 

To really enjoy the history of surgery it is necessary to consult the 
original documents — to get the flavor of the quaint phraseology of the 
older writers. No discourse about the surgical knowledge of Hippoc- 
rates, however eloquent and eulogistic it may be, can give such an idea 
of his teachings as is to be obtained from a perusal of his writings. 

It is not to be expected that a man who is familiar with the resources 
of the surgery of the present day will be able to discover in the ancient 
records anything of much practical utility in his daily work which will 
be new to him ; nevertheless, if he desires to compare his experience in 
a particular case or class of cases with that of his predecessors — to obtain, 

Vol. I.— 2 1"! 



18 THE HISTORY AND LITERATURE OF SURGERY. 

as it were, a sort of " parallax in time " of the views which have been 
held on the subject which occupies him — he will often not be able to do 
this from the current text-books. It will be necessary that he should 
go back to the old masters, read, compare, and think ; and whenever he 
does this it is safe to say that his conclusions will be broader, wiser, 
established on a firmer foundation, and more interesting to those to 
whom he imparts them, than they will be if derived solely from his own 
experience. 

In the history of the development in civilization of nations and 
peoples, surgery almost necessarily precedes internal medicine with regard 
to accurate observation of lesions of the human body and of their results. 
Speculations about humors and fluxes, black bile and medical constitu- 
tions, vital spirits and the doctrine of signatures, did not much occupy 
the minds of the men of old in their attempts to note and describe the 
signs of different forms of fractures and dislocations, the danger of 
wounds in different localities, the different varieties of tumors, or the 
treatment of a calculus in the bladder or of a hernia. Of the many 
remedies in the form of drugs, salves, embrocations, and plasters which 
are described at length in the ancient medical books which have come 
down to us, hardly more than twenty are now in ordinary use ; the 
ancient physiology and pathology are, for the most part, now considered 
as being merely curious illustrations of human error ; and it is only a 
portion of the anatomy and surgery of the ancients that remains as an 
essential part of the foundation of the art of medicine as it exists to-day. 

The history of surgery is inextricably mingled with that of medicine, 
and the best literature on the subject is to be found in some of the larger 
formal treatises on the history of medicine. It has, however, been treated 
of as a special branch of the art in a goodly numberof books and essays, 
the titles of a portion of which fill seven pages of volume xiii. of the 
Index Catalogue of the Library of the Surgeon-General's Office at Wash- 
ington. 

The earliest records in our possession which relate to surgical opera- 
tions come from Egypt. It is true that human skulls have been found 
belonging to the Neolithic or Polished Stone Age, which have had por- 
tions removed — being examples of the so-called prehistoric trephining 
which is supposed to have been performed in cases of headache, epilepsy, 
etc. — and the age of these relics is unknown ; but it is not at all probable 
that it extends to the time of the pyramid-builders in the valley of the 
Nile, when circumcision had been established as a religious rite and an 
official system of medicine was in process of construction. 

The Papyrus Ebers, written 1552 b. C. — that is, at least a century 
before the exodus of the Israelites — is a compilation of receipts and 
directions for the treatment of various diseases, many of which formulae 
it refers to as being then ancient. Among these is a short section on 
tumors near the surface of the body, in which it is said : " If this tumor 
goes and comes under your finger, trembling even when your hand is 
still, say, ' it is a fatty tumor,' and treat it with the knife, after which 
treat it as an open wound." From the Papyrus Ebers we learn that 
there were physicians in Egypt who were not priests, and the same may 
be inferred from the statement in Genesis (ch. 1. 2) that " Joseph com- 
manded his servants the physicians to embalm his father, and the phy- 



THE HISTORY AND LITERATURE OF SURGERY. 19 

sicians embalmed Israel." The word in this text which is translated 
" physicians " is rephaim, and it is sometimes translated as " dressers of 
wounds" — i. e. surgeons. The embalmers probably had a little more 
anatomical knowledge than the physicians of the time ; but the Egypt- 
ians had a treatise on anatomy which, according to Manetho, was attrib- 
uted to Athothis, the son of Menes, who reigned 5241 b. c. 

The few allusions to medicine scattered through the books of the 
Old Testament indicate that the general belief was in accord with that 
usually found prevailing among savage tribes — viz. that most diseases 
are punishments inflicted by divine power, and to be removed by sacri- 
fices and special ceremonies ; whence it follows that the priests were the 
chief medicine-men. That there were other physicians is probable from 
the grimly sarcastic account of King Asa, who " in his disease sought 
not to the Lord, but to the physicians. And Asa slept with his fathers ;" 
and also, perhaps, from Exodus xxi. 19 : "And if men strive together, 
and one smite another with a stone, or Math his fist, and he die not, 
.... then shall he that smote him pay for the loss of his time, and 
shall cause him to be thoi'oughly healed ; " or, as the Septuagint has it, 
"and shall pay the physician's fees." 

The medicine of the Bible has been the subject of several learned 
essays, but it does not appear that medicine was regularly studied among 
the Jews as a separate profession until the rise of the Alexandrian 
School, nor does either the science or the art of medicine owe anything 
to this nation until after this period. The often-quoted chapter xxxviii. 
of Ecclesiasticus about the physician is of late date, and was probably 
written under Greek influence. 

Some specimens of Jewish surgery prior to 200 A. D. are to be found 
in the Talmud. The rabbis were acquainted with sutures for wounds, 
with the method of freshening the edges of an old wound to obtain 
reunion, with the employment of the uterine sound to learn whether the 
blood came from the uterus or vagina, the operation for imperforate anus, 
and also with anaesthetic substances with which they used to diminish the 
pain of a surgical operation or capital punishment.' They understood 
the application to the body of artificial parts, as for supplying the loss 
of substance of the trachea and replacing the loss of substance of the 
cranial bone ; they knew artificial teeth, wooden legs, as also various 
forms of apparatus for the unfortunates who were deprived of the use 
of their lower extremities. 

The first allusions to surgical subjects in Greek literature are found 
in the poems of Homer, which may be accepted as dating from about 
1000 B. c, whatever may be thought as to the reality of the siege of 
Troy or the identity of Homer himself. In these poems mention is 
made of ^sculapius, not as a god, but as a well-known and distinguished 
physician, and of his sons Machaon and Podalirius as surgeons and war- 
riors. The works of Homer have been carefully examined and analyzed 
by Malgaigne and Daremberg with reference to medical and surgical 
matters, and their conclusions may be briefly stated as follows : ^ 

' Eabbinowicz: La Medecine du Thalrmid, etc., Paris, 1880, p. xliii. 

^ "Essai sur I'Histoire et I'Organisation de la Chirurgie et de la Medecine grecques 
avant Hippocrate," par M. Malgaigne, Jour, de Med., iv. 303, Paris, 1846 ; La Mededne 
dans Homh-e, par Ch. Daremberg, 8°, Paris, 1865. 



20 THE HISTORY AND LITERATURE OF SURGERY. 

Among the Greeks were certain surgeons whose knowledge and skill 
were highly esteemed ; many of the warriors knew how to dress and 
bandage wounds, and some of the Grecian women had the same skill, 
corresponding to that possessed by the wives of the nobility in AVestern 
Europe in feudal times. The dressings applied to the wounds appear to 
have been for the most part simple emollients: the eifused _ blood was 
pressed out, the surface was washed with warm water, certain crushed 
roots or bruised leaves were applied to check hemorrhage. Over forty 
wounds in different parts of the body are described with more or less 
detail, and in such a way as to indicate that Homer gave the results of 
actual observation and experience ; and in the course of these descriptions 
a nomenclature is used which, anatomically, is much the same as that 
employed by Hippocrates. The different effects of wounds in different 
parts of the body are referred to, and a curious illustration of this occurs 
in the description of the injury of one of the horses of Nestor by an 
arrow from the bow of Paris (viii. 81-86). The wound was on the top 
of the head, penetrating to the brain, and it is said that the injured animal 
was convulsed and turned round and round the pole. This, as Malgaigne 
points out, corresponds to the modern discovery that such movements of 
rotation are produced by an injury of the cerebellum. 

The anatomical terms used by Homer relate mainly to the exterior 
of the body, and do not imply any greater knowledge of internal struc- 
ture than is possessed by every butcher ; but his allusions to the fatality 
of certain wounds embody the results of considerable experience. There 
is nothing of surgical interest in Greek literature between the time of 
Homer and that of the Hippocratic Writings, unless it be the passage in 
Aristophanes in which the slave of Lamachus calls for hot-water com- 
presses, etc. with which to dress the sprained ankle of his master. 

In the fifth and sixth centuries B. c. there were in Greece and Great 
Greece between fifty and sixty temples of ^sculapius, all of which were 
probably resorted to by the sick, but those which became specially cele- 
brated were those of Ehodes, Gyrene, Cnidos, and Cos. Those at Cnidos 
and Cos gradually became the most famous, and their so-called " schools " 
occupy a prominent place in the history of medicine. 

By the term " medical schools " as applied to Cos and Cnidos it is not 
meant that these were places for the public teaching of medicine, but 
rather that they were places where certain medical families had settled, 
and in each of which certain peculiar theories and methods of treatment 
prevailed, the phrase " school " being used much as we would now speak 
of the " French " or the " Munich " school in painting. 

In the vicinity of these temples there seem to have collected physi- 
cians who were not priests, and who belonged to an association or bro- 
therhood, the members of which either claimed to be descendants of 
JEsculapius or were admitted to the guild by adoption with special cere- 
monies. These were known collectively as the "^sclepiadse," and much 
confusion has arisen from the erroneous application of this term in later 
times to those who ministered in the temple. There is no doubt that the 
priests of the temple gave medical advice, but, if we are to judge from 
the specimens preserved to us in the forms of inscriptions and memorial 
tablets, it was not the sort of advice of which any use is made in the 
medical treatises of the Hippocratic school. 



THE HISTORY AND LITERATURE OF SURGERY. 21 

It is probable that the real or lay physicians kept records which were 
handed down from father to son, and were preserved as a valuable family 
heritage. That medicine was thus hereditary we know from the Hip- 
pocratic oath, and from the genealogies which are given of many of the 
celebrated physicians of Greece. According to Bertrand, this custom has 
come down to the present time. On one of the slopes of Pindus there 
are still five or six villages the inhabitants of which are supposed to be 
born physicians and surgeons, each family having its own specialty and 
its inherited tradition. If a son is wanting, the child of a stranger is 
adopted. 

There is no evidence that those who visited the temples seeking mirac- 
ulous cures were examined or treated by lay physicians, but there were 
certain attendants called zaeoroi who received the patients and assigned 
them to places beneath the porticos ; and from the information collected 
by them it is possible that the priest who impersonated the god, appearing 
in the night-watches, may sometimes have formulated his prophecies and 
instructions. 

The doctrines of the schools of Cos and Cnidos were committed to 
writing, the first work of the kind coming from the school of Cnidos, 
being what is known as the " Cnidian Sentences." Of this treatise there 
were at least two editions, and it was in existence in the time of Galen. 
A portion of it has been preserved to us in what are known as the Second 
and Third Books of Diseases, and in the Treatises on Internal Affections 
contained in the Hippocratic collections. 

In this portion four diseases of the kidneys are described. In the first 
there is acute pain in the loins, groin, and the testicle of the affected side 
(renal colic) ; there is frequent urination, with gradual suppression of urine 
and passage of sand, causing pain in the urethra. Apply warmth and 
purge with scammony. If the pain is great, use large enemata of warm 
water ; if a tumor forms, make an incision over the kidney and evacuate 
the pus. Such incision gives a chance of recovery ; without it death 
will follow. 

In the second form of disease of the kidney there are violent pains, 
as in the preceding form. The patient passes blood with his urine at the 
commencement of the disease, which is followed, after a time, by pus. 
If he preserves a strict rest, he will be cured rapidly, but if he makes 
effort, the pains will become sharper. When the kidney is filled with 
pus it swells out near the spine ; in this case make, over the swelling, an 
incision, generally deep, into the kidney. If you succeed in the incision, 
you will cure the patient at once ; if you fail, it is to be feared that the 
wound will not close, and the borders of the wound will contract and the 
cavity of the kidney will be filled with pus ; if this passes inward and is 
evacuated by the rectum, there is a chance of health ; but if it affects the 
other kidney, death is to be feared. Evacuants are to be used, and the 
same regimen as for the preceding case. Very often this disease termi- 
nates by a renal phthisis. 

The school of Cos followed with its collection of maxims, the " Prse- 
notiones Coacse." Its doctrines will be best considered in the work of 
its most illustrious disciple, Hippocrates, who was born at Cos about 460 
B. c. His father, Heraclides, and his grandfather were physicians, and 
he received his early education at the school of Cos, after which he went 



22 THE HISTORY AND LITERATURE OF SURGERY. 

to Athens and continued his studies, receiving the best education which 
the Golden Age of Greek civilization could furnish. 

The collection known as the " Hippocratic Writings " dates_ from a 
period about the time of Aristotle. Only a portion of these writingsare 
the works of Hippocrates himself; several are probably of more ancient 
date — two at least appear to belong to the Cnidian School, and some are 
by his disciples. On the other hand, some of those which once belonged 
to this collection have been lost. 

The books in the Hippocratic collection which treat more especially 
of surgical affections and operations, and which are accepted^ by most 
commentators as having been written either by Hippocrates himself or 
by one of his immediate pupils, are those on injuries of the head, on 
fractures, on the articulations (i. e. on dislocations), Mochlicus (on the 
bones and their injuries and displacements, and on apparatus), on wounds 
and ulcers, on fistulas, on hemorrhoids, and on the latrium or the Physi- 
cian's Establishment, or the Surgery. 

The book on injuries of the head begins with a description of the 
sutures of the cranium and of the bones of the skull, in which it is stated 
that the number and position of the sutures varies with the form of the 
head ; that the coronal suture is wanting when there is no anterior pro- 
tuberance of the skull, and the lambdoid suture is Avanting when there 
is no posterior protuberance. As this does not agree with the observa- 
tions of modern anatomists, the commentators have much trouble to 
explain it, since they are unwilling to admit that Hippocrates made a 
mistake in observation, or even that he generalized from insufficient 
data ; which last is the most probable explanation. 

He divides injuries of the bones of the skull into five classes — viz. 
simple fissures, contusions without fracture or depression, fractures with 
depression, indentations of the outer table, and fractures at a distance 
from the place of injury, or fracture by contre-coup. With regard to 
this last he says : " There is no remedy, for when this mischief takes 
place there is no means of ascertaining by any examination whether or 
not it has occurred, or on what part of the head." He then goes on to 
say : " Of these modes of fracture the following require trepanning : the 
contusion, whether the bone be laid bare or not ; and the fissure, whether 

apparent or not A bone depressed from its natural position 

rarely requires trepanning, and those which are most pressed and broken 
require trepanning the least." 

,It will be seen that this is quite different from the rules of modern 
practice. 

For wounds of the head he forbids the application of any liquors or 
cataplasms or tents, unless the wound is on the forehead or the part 
which is bare of hairs or about the eyebrow and eye. The wound is to 
be extended by incisions for the purpose of examining the bone when- 
ever it is suspected that this is injured ; and it is remarked that these 
incisions may be practised with impunity except on the temple and the 
parts above it, where there is a vein that runs across the temple, in which 
region an incision is not to be made ; " for convulsions seize on a person 
who has been thus treated ; and if the incision be on the left temple, the 
convulsions seize on the right side ; and if the incision be on the right 
side, the convulsions take place on the left side." 



THE HISTORY AND LITERATURE OF SURGERY. 23 

The books on fractures and on the articulations, together with the 
book called " Mochlicus," contain sketches of the anatomy of the bones 
and of the joints, and accounts of various forms of dislocations of the 
different joints, with detailed instructions as to reduction and as to the 
mode of bandaging in cases of fracture. Special attention is given to the 
subject of injuries affecting the knee-, the elbow-, and the ankle-joints. 

The paragraph on dislocations of the knee does not correspond to the 
experience of modern surgeons. It is as follows : " Luxations and sub- 
luxations at the knee are much milder accidents than subluxations and 
luxations at the elbow ; for the knee-joint, in proportion to its size, is 
more compact than that of the arm, and has a more even conformation, 
and is rounded, while the joint of the arm is large and has many 
cavities 

" Owing to their configuration, the bones of the knee are indeed fre- 
quently dislocated, but they are easily reduced, for no great inflammation 

follows nor any constriction of the joint They are displaced 

for the most part to the inside, sometimes to the outside, and occasion- 
ally into the ham. The reduction in all these cases is not difficult, but 
in the dislocations inward and outward the patient should be placed on 
a low seat, and the thigh should be elevated, but not much. Moderate 
extension for the most part sufficeth, extension being made at the leg and 
counter-extension at the thigh. 

" Dislocations at the elbow are more troublesome than those at the 
knee, and, owing to the inflammation which comes on and the config- 
uration of the joint, are more difficult to reduce if the bones are not 
immediately replaced. For the bones at the elbow are less subject 
to dislocation than those of the knee, but are more difficult to reduce 
and keep in their position, and are more apt to become inflamed and 
ankylosed." 

Some of the older surgeons concur with Hippocrates in speaking of 
dislocations of the knee as comparatively frequent, whereas at present 
they are very rare. Dr. Adams supposes that the wrestlers at the public 
games, who furnished Hippocrates with a large proportion of his cases 
of fractures and dislocations, may have been especially liable to this 
accident. Hippocrates says that he knows of but one way in which the 
shoulder-joint is dislocated — namely, that into the armpit ; but he does 
not deny that the head of the humerus might be dislocated upward, out- 
ward, or forward. The methods of reduction are fairly described, and 
are substantially those which are used at the present day. 

He has much to say in various places about congenital dislocations, 
some of which may be reduced to their natural condition, and especially 
those at the ankle-joint. 

In cases of compound dislocations he forbids reduction, as a general 
rule. For example, in speaking of dislocation at the ankle-joint com- 
plicated with an external wound, he says you are not to reduce the parts, 
but let any other physician reduce them if he choose ; " for this you 
should know for certain, that the patient will die if the parts are allowed 
to remain reduced, and that he will not survive more than a few days, 
for few of them pass the seventh day, being cut off by convulsions ; but 

sometimes the leg and foot are seized with gangrene But if not 

reduced nor any attempts first made to reduce them, most of such cases 



24 THE HISTOnr AND LITERATURE OF SURGERY. 

recover. The leg and foot are to be arranged as the patient wishes, only 
they must not be put in a dependent position nor moved about." 

In speaking of these compound dislocations he makes no allusion to 
cutting off the protruding end of the bone, but in another section he 
remarks that " complete resections of bones at the joints, whether the 
foot, the hand, the leg, the ankle, the forearm, the wrist, for the most 
part are not attended with danger, unless one be cut off at once by de- 
liquium animi or if continual fevers supervene on the fourth day." 

Hippocrates knew nothing about amputation of limbs as an operation 
through living parts or with a view to forming a stump of a particular 
shape. In cases of gangrene due to the crushing of the blood-vessels, or 
following fractures when the bandages have been applied too tightly, he 
remarks that the most of such patients recover, even when a portion of 
the thigh comes away or of the arm, and when the forearm and leg drop 
off the patients rapidly recover. 

The surgical part of the Hippocratic collection is much more in 
accordance with modern views than the medical part; but there are 
certain characteristics of all the books generally considered to have been 
written by Hippocrates himself which are worthy of special attention in 
connection with the high repute in which they have been held by med- 
ical men for over two thousand years. In the first place, it is evident 
that one of his special aims was to be entirely honest and truthful in his 
statements. He reports no marvellous cures, no specimens of extraor- 
dinary success in diagnosis where others had failed ; fatal cases are given 
as well as recoveries, and there are no hints that the former were not seen 
in time or that they had been improperly treated by others. He seems to 
have written mainly for the purpose of telling what he himself knew ; 
and this motive — rare among all writers — is especially rare among 
writers on medicine. 

A second characteristic of the Hippocratic Writings is the special 
attention given to those symptoms which indicate the effect which the 
disease is producing upon the body as a whole, including such phenomena 
as fever, debility, delirium, restlessness, and so-called critical discharges 
of various kinds ; while the special diagnostic signs of particular forms 
of disease of particular organs are given much less attention. 

The aphorism of Hippocrates concerning the efficiency of fire — 
namely, " that diseases which are not cured by medicines are cured by 
iron ; those which are not cured by iron are cured by fire ; those not 
cured by fire are incurable " — has been the cause of an enormous amount 
of suffering and of bad surgery to nearly the present century. 

Surgery op India and China. 

In the literature of India the first definite hymns, invocations, and 
charms connected with medicine are found in the fourth (or Atharva) 
Veda. The oldest existing medical work is the Charaka-samhita of 
which the Sanscrit text has been published in 1877, and of which an 
English translation is now in course of publication. Somewhat later 
probably, is the Susruta, of which two Sanscrit editions have been pub- 
lished ; also a Latin translation by Dr. F. Hessler, published at Erlangen 
in 1844. English translations are in progress of publication, and a sum- 



THE HISTORY AND LITERATURE OF SURGERY. 25 

mary is given by Dr. Wise in his history of Indian medicine. Both 
Charaka and Su§ruta profess to be, and are commonly said to be, commen- 
taries on the Ayur-Veda — i. e. the Veda of Life — but, in fact, there is no 
such work as the Ayur-Veda distinct from and preceding Charaka and 
Susruta. 

The date of composition of these works is unknown, and is variously 
estimated at from 1000 B. c. to 700 a. d. Recent authorities consider that 
the later date is the more probable one, and that the work took its present 
form under the influence of ideas derived from the Alexandrian School 
and the early Arab writers. It was certainly known in the ninth century 
A. D. Nevertheless, it shows little trace of a knowledge by the author of 
the Hippocratic Writings or of the discoveries of the Alexandrian anato- 
mists and surgeons, and it contains a number of things peculiar to itself 
and probably derived from ancient Indian traditions. 

The translation of Susruta by Anna Moreshvar Kunte, of which the 
first numbers were published in Bombay in 1877, begins as follows : 

" Salutation to Brahma, Prajapati, the twin Asvins, Indra, Dhan- 
vantari, Susruta, and others, 

" Now, hereafter, we shall narrate the chapter named the descent of 
knowledge (of medicine) just as it was taught to Susruta by the venerable 
Dhanvantari. Aupadhenava, Vaitarana, Aurabhra, Paushkalavata, Kara- 
virya, Gopura, Rakshita, Susruta, and his other friends in earnest 
addressed the venerable Dhanvantari, the respected of gods (then 
known by the name of Divodasa), the descendant of Kasiraja, who was 
leading the life of a hermit, surrounded by a number of sages : ' Sire ! 
we are moved with compassion, seeing human beings, though protected 
(by their kings), yet quite helpless, being afflicted with numerous bodily, 
mental, natural, and accidental maladies. We wish to be instructed in 
the Science of Medicine for the sake of public good, for earning our 
livelihood, and for allaying the sufferings of mankind desirous of health. 
Earthly and heavenly bliss depends upon it. Hence, Sire, we have come 
to you to become your pupils.' 

" To them said the venerable man : ' Ye are welcome. All of you, 
my lads, shall be taught and made to meditate. Ayur-Veda is an Upanga 
of the Atharva-Veda. The Self-born, after creating the universe, com- 
posed it in a thousand chapters, containing a hundred thousand verses. 
But, knowing the brevity of human life and the limitedness of human 
understanding, he reduced it to eight divisions. These are : 1. Shalyam, 
splinter (extraction) surgery ; 2, Shalakyam, inquiry into the disease of 
organs situated above the clavicles ; 3, Kayachikitsa treats of diseases 
affecting the whole body ; 4, Bhutavida treats of diseases of mind pro- 
duced by demoniacal influences ; 5, Koumarabhrityam, care and treatment 
of children ; 6, Agadatantram, doctrine of antidotes ; 7, Rasayanatantra, 
doctrine of elixirs ; 8, Vajikaranatantram, rules for increasing the gen- 
erative powers. Which of these do you wish to be taught ?' — ' Sire,' 
said they, ' teach us all, but begin with surgery first.' — ' Be it so,' said 
he. — They again requested him, saying, ' Susruta, after consulting us all, 
shall ask you for explanations (in matters of doubt), and whilst he is 
made to understand we shall also try to do the same.' — ' Well, then, my 
pupil, Susruta,' said he, ' the Science of Medicine has for its object the 
emancipation from disease of those who are afflicted by it, and the pres- 



26 THE HISTORY AND LITERATURE OF SURGERY. 

ervation of the health of those who possess it. Ayur-Veda is so called 
because by it health is gained or it brings health. The best portion of 
it I explain to you : try to follow me and judge by the four criteria of 
judgment — namely, inference, comparison, testimony, and perception. 
It is the best, because the first inflicted wound was healed (by itsknow- 
ledge), and the head of Yajna was united to his trunk. It is said that 
when Rudra cut of the head of Yajna the gods went to the twin Asvins 
and said to them, "You two are of a higher rank amongst us. We 
entreat you to join together Yajna's head and trunk." They complied 
with the request. For their sake the gods propitiated Indra and allowed 
them a share in his sacrifice. They forthwith joined the head and trunk 
together. Of all the eight parts of which the Ayur-Veda is composed, 
this is the best, from the speediness of its operations, from its including 
the use of appliances, surgical instruments, caustics, cauteries, and from 
its being common to the other parts (of the science). Thus it is eternal, 
meri1>-giving, divine, leading to renown, longevity, and prosperity. 

" ' The great god Brahma announced (the knowledge of medicine) 
first ; Prajapati learnt it from him ; the twin Asvins got it from Prajapati ; 
from them Indra; and from Indra have I learnt it. I am going to 
impart it to anybody who seeks it for the sake of public good. 

" ' On the preliminary preparations (rules to be observed before, dur- 
ing, and after the completion) of surgical operations : 

"'Every action (to be successful) involves three stages — viz. 1, 
the preparatory stage ; 2, the predominant stage ; 3, the succeeding 
stage. We shall point out that the treatment of diseases has these 
three stages. 

"'In this science the use of edged instruments is considered to 
be predominant. Hence we shall begin our description with it and 
its accessories. Edged instruments are used for eight purposes — viz. 1, 
amputating ; 2, opening ; 3, scarifying ; 4, puncturing ; 5, exploring ; 6, 
drawing ; 7, evacuating ; and 8, sewing. A surgeon contemplating to 
operate in any of the above ways should first have ready the following : 
blunt instruments (forceps, etc.), sharp instruments, potential cauteries, 
virtual cauteries, catheters, horns, leeches, a dry gourd, a cauterizing 
needle, stuffing materials, strings, board, bandage, honey, ghee, fat, milk, 
oil, soothing decoctions, injections, lotions, fan, cold and warm water, a 
frying-pan, able, steady, and attached servants. 

" ' Then on a good day, having a good lunar influence and the 
auspicious influence of stars, after invoking blessings from the Brah- 
mans and medical men, and propitiating the sacred fire with honey, rice 
and water, let the patient be seated, who has taken very little food 
offered sacrifices, and made ablutions, with his face toward the east. 
The surgeon should stand with his face toward him, and pluno-e his 
instrument after the proper incision until matter comes out, and Mdth- 
draw it, avoiding vital parts, vessels, muscles, articulations, bones, and 
arteries. In the case of a large collection of matter the incision may 
be of the breadth of two or three fingers even. 

"'Incisions are either long, wide, even, or uneven. An incision 
whether long, broad, clean, or dependent, is always to be extolled M'hen 
it suits (the purpose and) the occasion. Boldness, rapidity of action 
sharp instruments, operation without trembling, fear, or doubt, are always 



THE HISTORY AND LITERATURE OF SURGERY. 27 

praiseworthy of the surgeon operating The operations for moles, 

ascites, piles, calculus, fistula, and mouth diseases are to be performed on 

an empty stomach The instruments should be so made that they 

should be of a good finish, strong, clean in appearance, with good handles, 
whether they be sharp or blunt. 

" ' Among these the Svastika instruments ought to be about nine inches 
long ; their mouths should be respectively like those of a lion, tiger, 
wolf, hyena, bear, elephant, cat, hare, antelope, crow, heron, dog, jay, 
vulture, falcon, owl, kite, cock, crouch, the bee, rat, mouse, or bullock, 
each half being united to the other by a nail of the form of a lentil- 
seed, being bent inward at the handles like the elephant-driver's hook. 
These forceps are recommended for the extraction of splinters lodged in 
bones. 

" ' The tubular instruments are of a variety of kinds, having various 
uses, open at one end or both or having several foraminse. They are 
used for removing obstructions from the great canals of the body, or for 
examination of diseases, or as suction-tubes, or for the easy application 
of remedies. Their lengths are always determined by the aperture 
of the canal whence the obstruction is to be removed or by the use to 
which they are to be applied. 

" ' The different tubular instruments which are used in fistula, hemor- 
rhoids, polypi, sores, urethral injections, enemas, retention of urine, 
ascites, inhalation for cough and dyspnoea, and obstruction of bowels, 
together with the bottle-gourd and the horns, shall be described hereafter 
in their proper places. 

" ' The probe-like instruments are of various kinds and serve a variety 
of purposes. Their magnitudes differ according to the uses they are 
applied to. Among them the earthworm-like probe, the arrow probe, 
the serpent-hood probe, and the hook probe are each of them two in 
number. They have been recommended for sounding, separating, loosen- 
ing, and extracting (foreign bodies). Probes having lentil-seedlike ends 
are two. They are slightly curved inward at their extremities, and are 
used for the extraction of foreign bodies from the large canals. There 
are six probes which are capped with cotton wool, and are used for 
cleaning and wiping purposes. There are three which are ladle-like and 
mortar-like, and are used for application of caustics. Three others there 
are which have their ends like a jambul-seed. Three others, again, resem- 
bling the elephant hook. These six are used for cauterizing purposes. 
There is a nasal-polypus probe which resembles the kolasthi. There is 
the inunction probe, which at its both extremities has a knob like the 
pea-seed, resembling an open bud. There is the urinary catheter, which 
resembles the stalk of malati- \Jasminium glandiflo7'a] flower, and its 
length varies according to purpose 

" ' The lion-mouth forceps is for foreign bodies that can be seen, while 
for covered ones there is the heron forceps and others of its kind. These 
should be used gently, the foreign body being removed in accordance 
with surgical precepts. 

" ' The heron forceps is the best of all forceps, since its use never leads 
to accidents. It enters easily and is very easily drawn back. It lays a 
firm hold on splinters and removes them easily.' " 

No allusions are made to the use of the ligature, but amputations of 



28 THE HISTORY AND LITERATURE OF SURGERY. 

the limbs were performed, the hemorrhage being checked by the cautery, 
by boiling oil, and by pressure. 

The operation of lithotomy is described, being that of "^ cutting on 
the gripe," the incision being made on either the left or the right side of 
the perineum, the breadth of a barley-corn from the central line and an 
inch from the anus. 

The suprapubic operation was also known, rhinoplasty is described, 
and herniotomy is referred to. Manual skill was to be acquired by the 
student by making punctures and incisions on gourds and other fruits or 
on dead animals. 

Fractures and dislocations are described with considerable detail of 
classification, and the bamboo splints recommended are still in use. The 
most original thing in the work is the part which relates to plastic sur- 
gery, and especially to rhinoplasty. 

Of the history of surgery in China almost nothing is known. Hwa 
T'o, who is supposed to have lived in the third century A. D., is ordinarily 
considered to have been the father of surgery in China. He is said to 
have performed abdominal section for the local treatment of diseased 
viscera ; to have laid bare the scapula of a certain great military hero 
and scraped from it cejiain poison, possibly carious bone ; also to have 
relieved by acupuncture an affection of the brain of another famous 
general of his time. It does not appear that this was entirely successful, 
however, for he subsequently proposed trephining for the surgical cure 
of this disease, on which the indignant general is stated to have declared 
him a traitor who was plotting his death, and to have had him beheaded. 

Ch'an Kwei in the sixth century a. d. is also said to have successfully 
removed certain diseased viscera by incision through the abdominal wall. 

These stories rest upon no definite foundation. Acupuncture, counter- 
irritation, and various forms of shampooing seem to have been the only 
forms of surgical treatment practised in this nation, and operative surgery 
is now, as it probably always has been, practically unknown among the 
Chinese. 

After the time of Hippocrates there is very little of interest from a 
surgical point of view recorded in Greece itself. His sons, Thessalus 
and Draco, and his son-in-law, Polybius, were also physicians, and are 
supposed to be the authors of some of the books in the Hippocratic col- 
lection. Aristotle gave a strong stimulus to the study of anatomy, and 
is said to have written two books on medicine, which have been lost. 
Through the influence of his pupils the famous library, museum, and 
schools of Alexandria were formed, and the headquarters of medical 
knowledge for the time being passed to Egypt. The Alexandrian School 
is famous for the advances in the knowledge of human anatomy which 
were made there as a result of the authority M'hich was, for a short time 
granted for the dissection of human bodies. The numerous writings of 
the anatomists of this school have been lost as distinct works, but prob- 
ably all their important discoveries and teachings have been preserved 
for us in the works of Celsus, Galen, and Oribasius. Herophilus (about 
300 B. c.) was perhaps the most famous of these anatomists, and many 
of the names of parts which he gave are in use to-day, such as the 
choroid, the retina, the dura and pia mater, the calamus scriptorius the 
duodenum, and the prostate. Erasistratus, his contemporary and rival 



THE HISTORY AND LITERATURE OF SURGERY. 29 

was also a famous anatomist, but we know even less of his work than we 
do of that of Herophilus. Galen says that he invented the catheter, but 
it is probable that this instrument was known both in Egypt and in 
India long before. 

The advances in surgery made by the Alexandrian School prior to 
the Christian era are practically summed up in the first treatise on sur- 
gery written in Latin which has come down to us — namely, that of Celsus, 
or, more properly, of Aulus Cornelius Celsus. Of the personality of 
this writer we know nothing positively, but he probably lived at Rome 
about the beginning of the Christian era, and was not a physician by 
profession, medicine at that time being almost exclusively practised by 
Greeks. He is quoted by Pliny as an author as distinguished from a 
physician, and his work was not referred to by any medical writer for 
over a thousand years after his death. His book was a sort of encyclo- 
paedia of the arts and sciences of his time, intended for educated men, 
but not specially for physicians, and the medical portion consists of 
eight books or sections, which, in the original, followed the five books 
of the treatise on agriculture — the first book of the " De re Medica " 
being in the oldest Vatican manuscript entitled "Auli Cornelii Celsi 
liber sextus, idemque medicinse primus." After the invention of printing 
the " De re medica " of Celsus was one of the first books that issued 
from the press, having been published in 1478, since which date there 
have been over sixty Latin editions and translations into most modern 
languages. 

Most persons not familiar with the history of the art are accustomed 
to place Celsus with Hippocrates and Galen as one of the three great 
Fathers of Medicine ; but he was really only a compiler, although a 
compiler whose conciseness and clearness of style have gained for him the 
title of " the Medical Cicero." As Greek was the professional language 
of his day, he could find no Latin equivalent for many of the technical 
terms, and was obliged to use either a descriptive periphrasis or to give 
the Greek word, introduced by the phrase " the Greeks call it." He was 
also troubled by the fact that in writing in Latin on the subject of hernia 
he was compelled to use what was considered to be a very immodest and 
improper word, for which he duly apologizes ; and this is one of the 
numerous proofs that his work was not intended for physicians espe- 
cially, but for the educated public. 

A compiler without practical experience is sure to make some mis- 
take ; and a good illustration of this is found in the remarks of Celsus 
upon dislocation of the hip, as pointed out by Broca. Dislocation of 
the hip-joint, prior to the discovery of ansesthetics and the introduction 
of Reid's method, was often very difficult to reduce ; but after it had 
once been reduced there was no special difficulty in keeping the head of 
the femur in its proper place. Celsus had probably never seen a case, 
but he had heard that one of the great dangers is that when reduced it 
may slip out again, this idea having probably arisen from confounding 
fracture of the neck of the femur with dislocation of its head ; so he 
argues as follows : " Some maintain that it always does so [i. e. slips out 
again], but Hippocrates, Diodes, Philotinus, Nileus, and Heraclides the 
Tarentine, very celebrated authors, have asserted that they have effected 
a perfect cure. Neither would Hippocrates, Andreas, Nileus, Nympho- 



30 THE HISTORY AND LITERATURE OF SURGERY. 

dorus, Protarchus, Heraclides, and also a certain mechanician have 
invented so many kinds of machines for extending the femur in this 

case if it had been to no purpose Therefore it must be attempted.^ 

The logic is excellent, but the point which he supposes to be in dispute is 
wholly imaginary. 

Some of the details of surgical practice given by Celsus will be con- 
sidered in connection with those found in other writers next to be referred 
to. Of these the chief is Claudius Galen, who was born at Pergamus 
131 A. D. He studied medicine at the schools of Smyrna, Corinth, and 
Alexandria, and returned to Pergamus at the age of twenty-eight, when 
he was appointed to the medical charge of the athletes of the gymnasium 
connected with the temple of ^sculapius. Four years later he went to 
Rome, where he soon became celebrated. He finally returned to his 
native country, where he died when about seventy years old. He is 
said to have written five hundred treatises on medicine, but a large 
number of these have been lost, and a number which exist in manuscript 
have not been printed. 

The medical system of Galen is happily compared by Daremberg 
to a tissue of which the Hippocratic "Writings are the woof and those 
of Aristotle the warp. His anatomy is mainly contained in his treatise 
" De usu partium," the purpose of which treatise is to prove that all the 
organs of the body are arranged in the best possible manner and show 
the wisdom and care of Nature. After a few preliminary definitions he 
begins his third section as follows : " As man is the wisest of all animals, 
so the hands are the instruments which belong to a wise being. For 
man is not the wisest of animals because he has hands, so says Anaxa- 
goras, but he has hands because he is the wisest, as says Aristotle, who 
judges very judiciously. In fact, it is not by his hands, but by his 
reason, that man has learned the arts. The hands are an instrument, as 
the lyre for the musician or the pincers for the blacksmith." 

Between the time of Celsus and that of Galen there were three 
writers whose names should be mentioned in a sketch of ancient sur- 
gery, although their works have for the most part been lost — namely, 
Soranus of Ephesus, about 79-138 A. v., and Rufus of Ephesus, and 
Heliodorus, about the beginning of the second century. The treatise 
of Soranus on the diseases of women, edited and translated into Latin 
by Ermerius, was published in 1869, and his "De signis fracturarum " 
was published by Cocchius, with a translation, in 1754. A considerable 
part of his medical writings form the books ordinarily attributed to 
Ceelius Aurelianus. Such works of Rufus as have been preserved were 
edited and translated into French by Daremberg, and published in 1879. 
Heliodorus lived at Rome in the time of Trajan, about the beginning of 
the second century A. D., and wrote a treatise on surgery, the fragments 
of which, preserved for us by Oribasius, indicate that he must have been 
a skilful surgeon, well acquainted with anatomy and with various modes 
of operating which have been proclaimed as marvellous in later days, 
such as the torsion of arteries, a particular mode of operating for the 
radical cure of hernia by excision of the sac, the excision of stricture 
of the urethra, etc. 

After Galen, probably about the end of the third century, came a 
surgeon named Antyllus, who seems to have been a skilful operator and 



THE HISTORY AND LITERATURE OF SURGERY. 31 

an original writer, but of whose works we have only fragments preserved 
in the writings of Oribasius, a native of Pergamus, who was the physi- 
cian and friend of the emperor Julian about the middle of the fourth 
century. Oribasius wrote a huge medical cyclopaedia, which formed 
seventy books, of which over two-thirds have been lost, but what 
remains is of much interest in an historical point of view, because he 
copied literally, or nearly so, the text of the authors from whom he 
compiled, often giving their names, and in this way has preserved frag- 
ments of many works of which we have no other means of knowledge. 

The next in time of the great medical compilers and encyclopaedists 
is -3iltius Amidenus, who lived in the early part of the sixth century, 
studied medicine in Alexandria, and practised at Constantinople, where 
he became famous. He wrote a work in four books, each containing four 
sections, which is known as the " Tetrabiblos." There are no translations 
into modern languages. It is an important work in the history of sur- 
gery, containing extracts from previous authors not found elsewhere, and 
it supplements, to some extent, what remains to us of Oribasius, as it 
contains copies of some of the lost sections of that writer. He describes 
charms and amulets, in which he had full faith, and he has been supposed 
to have been a Christian, because in extracting a bone he recommends 
the use of the following word-charm : " Bone, as Jesus Christ caused 
Lazarus to come out of the grave, as Jonah came out of the wliale's 
belly, come out ! " 

Following ^tius, about the middle of the sixth century was Alex- 
ander of Tralles, a Lydian, who practised at Kome, and wrote a work on 
medicine in twelve books, the Greek text of which was first published at 
Paris in 1548. He was a Christian, and made use of amulets and incan- 
tations, of which he gives several specimens. 

Paul of ^gina (Paulus ^gineta), the last of the Greek writers on 
medicine, lived in the early part of the seventh century and studied at 
Alexandria. His seven books are among the most famous of medical 
classics, and form a compend and abridgment of the medical literature 
of his day carefully selected and concisely expressed. His main source 
of information appears to have been the works of Oribasius. He does 
not pretend to any originality, as will be seen by the following extract 
from his preface : " It is not because the more ancient writers had omitted 
anything in the art that I have composed this work, but in order to give 
a continuous course of instruction ; for, on the contrary, everything is 
handled by them properly and without any omissions, whereas the 
moderns have not only in the first place neglected the study of them, 

but have also blamed them for prolixity To remember all the 

rules of the healing art and all the particular substances connected with 
it is exceedingly difficult, if not altogether impossible. On this account 
I have compiled this brief collection from the works of the ancients, and 
have set down little of my own, except a few things which I have seen 
and tried in the practice of the art." The sixth book is a system of 
operative surgery, the most complete of any which have come to us from 
before his time, and the source of most of the surgical treatises of Arabian 
authors. In it he never refers to Celsus, but often to Galen. 

Having thus given a brief account of the principal Greek and Latin 
writers on surgery whose works are known to us, we may now consider 



32 THE HISTORY AND LITERATURE OF SURGERY. 

the progress in the art which had been made between the time of Hippoc- 
rates and that of Paul of ^gina, a period of about one thousand years 

First, as to hemorrhage from recent wounds, and more especially 
arterial hemorrhage. Upon this subject the Hippocratic Writings contain 
nothing. Celsus says (lib. v. cap. xxvi.) : " If we fear the hemorrhage, 
the wound is to be filled with dry pledgets of lint, and a sponge squeezed 
out of cold water is to be applied and compressed with the hand. If the 
blood still issues, the lint must be changed frequently, and if dry lint 
does not succeed, it should be moistened with vinegar. Caustics should 
not be used, except in urgent cases, on account of the inflammation 
which follows their use. If compression, cold, and vinegar fail to stop 
the bleeding, the vessels which pour out the blood are to be seized and 
tied with two ligatures, one on each side of the wounded part, after which 
the vessels are to be divided between the ligatures, that they may retract 
and still have the openings closed. If the case does not admit of this,' 
the actual cautery may be used." Celsus makes no reference here to any 
distinction between arterial and venous hemorrhage. In speaking of 
castration he says : " The veins and arteries must be secured by a liga- 
ture at the groin and divided behind it." This is the first mention of 
the ligature of blood-vessels in published literature : it was an invention 
of the Alexandrian School, and is said to have been introduced at Rome 
by Euelpistus, who lived a short time before Celsus. 

Galen refers in several places to the use of the ligature, but treats 
more especially of hemorrhage in the fifth book of the Methodus Medendi. 
He directs that the finger be placed gently upon the mouth of the bleed- 
ing vessel, extending and compressing it. If the wounded vessel lies 
deep, the surgeon must thus learn its position and size, and then, whether 
it be a vein or an artery, lift it with a hook and tAvist it a little. If this 
does not answer and it is a vein, styptics, such as roasted rosin, fine 
flour, gypsum, etc., are to be tried ; but if it is an artery, it must be either 
ligated or entirely divided. Sometimes the veins must also be ligated 
and divided ; but it is safer to do both — that is, to ligate the proximal 
end of the vessel and also to divide it beyond the ligature. Oribasius 
says nothing about the ligature, but advises the cautery if the bleeding 
cannot be checked otherwise. Paulus ^gineta copies Galen almost 
literally, but says, in addition : " You may know whether it is a vein or 
an artery that pours forth the blood from this, that the blood of an artery 
is brighter and thinner and is evacuated by pulsations, whereas that of 
the vein is blacker and without pulsation." 

While it is thus evident that the use of the ligature was known from 
the beginning of the Christian era, it is curious that it seems never to 
have been employed to check hemorrhage from vessels divided in ampu- 
tations. 

Celsus remarks that in cases of gangrene of an extremity the incision 
is to be made between the sound and the corrupted part, but says nothing 
about details. Galen's advice is the same as that of Hippocrates. Paulus 
says : " Leonides properly directs us not to divide all the parts at once 
unless they are completely mortified, but first to cut the part where not 
many nor very large veins or arteries are known to be situated, down to 
the bone quickly ; then to saw the bone as rapidly as possible, applying 
a linen rag to the parts which have been cut, lest they be torn bv the 



THE HISTORY AND LITERATURE OF SURGERY. 33 

sawing and cause pain, and then, having cut through what remains, to 
apply red-hot irons to the vessels, and stop the hemorrhage thereby with 
compresses of lint." The Leonides referred to here was an Alexandrian 
surgeon who lived about the beginning of the third century A. D. Prior 
to this, however, Archigenes, a celebrated physician who lived at Rome 
about the beginning of the second century A. D., and Heliodorus, had 
given more details as to methods of amputation, as appears from the 
fragments of their works preserved in the collection of Nicetas, published 
byCocchius in 1756. Archigenes appears to have commenced the opera- 
tion in some cases by a preliminary ligature of the blood-vessels supply- 
ing the parts ; the incision was a circular sweep down to the bone. The 
red-hot iron was used to check hemorrhage. The method of Heliodorus 
is substantially the same as that of Leonides. 

Aneurism is not mentioned by Hippocrates or by Celsus. Galen 
describes it in his Mork "De tumoribus," saying that it may arise 
either from simple dilatation or from a wound of an artery, and is 
recognized by its pulsation. The only treatment he refers to is com- 
pression by means of sponge. 

The following is an extract from the treatise of Antyllus on aneurism, 
as given by Oribasius : " There are two kinds of aneurysm. In the first 
the artery has undergone a local dilatation ; in the second the artery has 
been ruptured. The aneurysms which are due to dilatation are longer 
than the others. The aneurysms by rupture are more rounded. To 
refuse to treat any aneurysm, as the ancient surgeons advised, is unwise ; 
but it is also dangerous to operate upon all of them. We should refuse, 
therefore, to treat aneurysms which are situated in the axilla, in the 
groin, and in the neck, by reason of the volume of the vessels and the 
impossibility and danger of isolating and tying them. We should not 
touch an aneurysm of large volume even when it is situated in some 
other part of the body. We operate in the following manner upon 
those which are situated upon the extremities and the head : If the 
aneurysm be by dilatation, make a straight incision through the skin in 
the direction of the length of the vessel, and, drawing open by the aid of 
hooks the lips of the wound, divide with precautions the membranes which 
cover the artery. With blunt hooks we isolate the vein from the artery, and 
lay bare on all sides the dilated part of this last vessel. After having 
introduced beneath the artery a probe, we raise the tumor and pass along 
the probe a needle armed with a double thread in such a manner that 
this thread finds itself placed beneath the artery ; cut the threads near 
the extremity of the needle, so that there will be two threads having 
four ends ; seizing, then, the two ends of one of these threads, we bring 
it gently toward One of the two extremities of the aneurysm, tying it 
carefully ; in like manner also we bring the other thread toward the 
opposite extremity, and in this place tie the artery. Thus the whole 
aneurysm is between the Uxo ligatin-es. We ojien then the middle of 
the tumor by a small incision : in this manner all which it contains will 
be evacuated, and there will be no danger of hemorrhage. 

" To tie, as it has been advised, the artery on both sides the vein, and 
then to extirpate the dilated part which finds itself between, is. a dan- 
gerous operation ; frequently, in fact, the violence and tension of the 
arterial pneuma push oif the ligatures. 

Vol. I.— 3 



34 TSE HISTORY AND LITERATUBE OF SUBGEBY. 

" If the aneurysm owes its origin to the rupture of the artery, we 
isolate with the fingers as much of the tumor as we can, includmg the 
skin, after which we pass underneath the isolated part the needle with 
the double thread and proceed as before ; after which the tumor may be 
opened at its summit and the superfluous portion of the skin cut away." 

Upon injuries of the skull and trephining Celsus speaks at consider- 
able length, quoting fully from Hippocrates. To distinguish a fissure 
from a suture he advises the pouring of ink on the part and then scraping 
the bone ; if there is a fissure, the ink will mark it. He says that if 
blood is extravasated beneath the cranium, the overlying bone will be 
pale. If no dangerous symptoms come on, he would defer operating on 
the bone for five days. All depressed bone is to be removed, but no 
more is to be taken away than is necessary. Galen preferred the use of 
small gouges, and of an instrument called a lenticular, to that of the 
trephine. He says that all greatly bruised (and depressed) bone is to be 
removed, but that simple fissures do not require operation. Paulus cojpies 
Galen. It will be seen that the Greek and Roman methods did not differ 
greatly from those of the present day. 

In fractures of the spine Paulus says that, " having first given warn- 
ing of the danger, we must, if possible, attempt to extract by an iricision 
the compressing bone," and that the same is to be done in case of frac- 
ture of one of the spinous processes. 

Celsus (lib. v. cap. xxviii.) describes carcinoma as usually occurring 
about the face, and in the breasts of females, but says that it may also 
occur in the liver or spleen. It is the seat of some lancinating pains, is 
tumefied, immovable, and unequal, and the veins about it are swollen 
and tortuous. It commences by what the Greeks call cacoethes, then 
proceeds to carcinoma or scirrhus without ulceration, then to an ulcer 
which becomes fungous. " None of these can be removed except the 
cacoethes ; the rest are aggravated by every method of treatment, and 

the more energetic the remedies the more irritable they become 

None were ever treated successfully with medicine ; . . . . after excision, 
though a cicatrix has been formed, they have returned again and carried 

off the patient But no one can distinguish a cacoethes, which is 

curable, from a carcinoma, which is incurable, except by time and 
experiment." 

Galen describes cancer at greater length, but adds nothing to the 
means of diagnosis : the only chance of cure lies in excision, but if this 
be performed the arteries must not be tied. 

Paulus merely abridges Galen's description, says nothing about an 
operation, and advises external applications. A hard tumor which is 
wholly insensible is incurable. 

Cystic tumors, including atheroma, meliceris, and steatoma, are briefly 
but clearly described by Celsus (lib. vii. cap. vi.) ; they are to be removed 
by incision : in steatoma the cyst must be divided, in the others it may 
be removed entire. Antyllus gives a more detailed description which 
is quoted by Oribasius (lib. xlv.). 

The Hippocratic oath requires that lithotomy be left to those who 
make a special business of it. The first author who describes the opera- 
tion is Celsus (lib. vii. cap. xxvi.). He says it should only be performed 
in the spring, and on children between the ages of nine and fourteen and 



THE HISTORY AND LITERATURE OF SURGERY. 35 

in urgent cases when medicines have failed, although he admits that a 
rash operation now and then succeeds. The operation described is that 
which is commonly known as " cutting on the gripe," or, in modern 
times, as the " Celsian operation." The description given by Celsus is 
detailed, and in most points is very clear (lib. vii. cap. xxvi.). The essen- 
tial principle is to force the stone down into the neck of the bladder and 
hold it there by two fingers introduced into the rectum, after which a 
lunated incision is to be made through the skin of the perineum imme- 
diately over and extending to the neck of the bladder, and a second 
incision in the convex part of the wound, so as to open the neck of the 
bladder freely ; and the wound should be a little larger than the calculus, 
for those who dread a fistula make too small an opening, and are after- 
ward reduced to the same inconvenience with still greater danger, because 
the calculus when forced will make a passage unless it find one ; and this 
is even still more injurious if the form and inequalities of surface have 
contributed in any way to this eflPect. If the stone is so large that it 
cannot be extracted without lacerating the neck of the bladder, it must 
be split according to the method of Ammonius, who was known as Lith- 
otomus, the stone-cutter. It is done in this manner : A crotchet is intro- 
duced to the calculus, so as to hold it fast while being struck, lest it 
should recoil backward ; then an iron instrument of moderate thickness 
is to be employed, the one extremity of which is thin, but blunt, and 
being applied to the stone and struck at the other extremity, splits it, 
great care being taken that neither the instrument itself nor any frag- 
ment of the stone should injure any part. 

There is practically nothing to add to this description by other Greek 
writers until we come to the time of Paulus, whose description is much 
the same as that of Celsus. He says that children up to the age of four- 
teen are the best subjects for the operation : old men are difficult to cure, 
because ulcers of their body do not readily heal, and intermediate ages 
have an intermediate chance of recovery. The stone is to be brought 
down by the fingers in the rectum, as described above ; then " we take 
the instrument called a lithotome, and between the anus and the testicles 
— not, however, in the middle of the perineum, but on one side, toward 
the left buttock — we make an oblique incision, cutting down direct upon 
the stone where it protrudes, so that the external incision may be wider, 
but the internal not larger than just to allow the stone to fall through it. 
Sometimes, from the pressure of the finger or fingers at the anus, the 
stone starts out readily at the same time that the incision is made, with- 
out requiring extraction ; but if it does not start out of itself, we must 
extract it with the forceps called the stone-extractor." . ..." If the 
stone, being small, fall into the penis and cannot be voided with the urine, 
we may draw the prepuce strongly forward and bind it at the extremity 
of the glans. We must next apply another ligature round the penis behind 
the member, making the constriction at its extremity next the bladder, 
and then make an incision down upon the stone, and, bending the penis, 
we eject the stone, and undoing the ligatures we clear away the coagula 
from the wound. The posterior ligature is applied lest the calculus 
should retreat backward, and the anterior in order that, when untied 
after the extraction of the stone, the skin of the prepuce may slide back- 
ward and cover the incision." 



36 THE HISTORY AND LITERATURE OF SURGERY. 

After the capture of Alexandria by the newly-risen Mohammedan 
power, about 640 a. d., the Arabians became the inheritors and preservers 
of the science of the Greeks. The first notions of medicine obtamed by 
the Arabs were probably derived from Persia, if we may judge by the 
names of a great number of their drugs, and the medical knowledge of 
Persia came in part from India and in part from Greece. 

The first Arab physician of note was Hareto Ben Coladoh, who lived 
about the middle of the sixth century, and who seems to have studied 
medicine under the Nestorians, a Christian sect dating from the early 
part of the fifth century and occupying the ancient countries of Assyria 
and Persia. The Nestorian physicians appear to have been very zealous 
in collecting and preserving all the medical works which could be found 
at that time, including those of the Hippocratic collection and the 
writers of the Alexandrian School. In the mean time, after the destruc- 
tion of Jerusalem, certain Jewish physicians and teachers had settled in 
Alexandria, and after the fall of that city we find some of these Jewish 
physicians taking somewhat prominent positions and being collectors 
and translators of the medical literature of the Greeks. The so-called 
" Arabic books on medicine " were largely compends and summaries of 
the works of Greek writers which had been translated into Syriac or 
into Hebrew, and thence into Arabic, or, in some few cases, directly into 
Arabic. There are very few of these which contain any matter of interest 
to the history of surgery. 

The most famous of their writers was Avicenna (980-1036 A. D.), a 
native of Persia, who for five hundred years rivalled Galen as an authority, 
and, like him, was called the Prince of Physicians. The medical Avorks 
of Avicenna, known as "The Canon," are a sort of encyclopaedia, in 
which the opinions of the Greeks and of Galen are mingled with Oriental 
philosophy, forming a very prolix and in many places obscure treatise 
upon all subjects connected with medicine. It was translated into Latin 
by Gerard of Cremona, and became for a time the principal guide for 
European physicians, its high repute being probably due in part to the 
difficulty of understanding it. 

The most celebrated writer on surgery of the Arabian School was 
Albucasis, also known as Bulchasis, Abulcasis, or Alsaharavius, and 
properly as "Khalaf Ibn 'Abbis (Abu Al-Kfisim) Al-Zahrawi." He 
was born at Zahra, near Cordova, and died about 1105 A. d. His great 
work, Al Tesrif or Tasrif — i. e. the collection or encyclopsedia — included 
thirty books upon all branches of medicine, but of these only a part have 
ever been published. The three books of his works on surgery, forming 
a special treatise (book xxx. of Al Tesrif), were published in Arabic and 
Latin under the editorship of John Channing at Oxford in 1778 and 
this is the best printed edition which is available, although in some 
respects it is obscure and unsatisfactory. A translation into French was 
made by Dr. Leclerc and published in the Gazette mklicale de VAlqhie 
in 1858-61, and afterward issued as a reprint (Paris, 1861) ; and this is 
the most convenient edition to consult for most purposes. 

The work is divided into tliree books. The first is devoted to the 
actual cautery and the use of caustics, Avith elaborate descriptions of the 
instruments which are figured. In fact, Albucasis is the first author 
whose works have come down to us who has given figures and good 



THE HISTORY AND LITERATURE OF SURGERY. 37 

descriptions of surgical instruments. The second book relates to incisions 
of all kinds, bloodletting, scarification, treatment of wounds, and the 
extraction of arrows and missiles, and the third is devoted to the treat- 
ment of fractures, luxations, sprains, etc. 

The treatise in general is a clear and comparatively concise statement 
of methods of treatment. A large part of it is evidently derived from 
Paul of ^gina or from the original authorities from which Paul of 
iEgina copied, and it is hard to say how much of his work is really 
original ; but it was the highest authority on the subjects of which it 
treats during the period of the revival of letters in \Vestern Europe, 
and is a very important work for the student of the history of surgery 
or of surgical operations. The following are some specimens of his 
teachings : 

In speaking of the operation of arteriotomy upon the temporal 
arteries he directs that a portion of the vessel be cut out, so that the 
two ends may separate in order to prevent hemorrhage. If the artery 
is large, it is necessary to tie it in two places — at two points — ^with a 
strong double thread of silk or of the cord used in instruments of music 
(catgut), in order that it may not alter before cicatrization takes place, 
which would bring on a hemorrhage. This ligature should be double, 
and the operator is to take away the intermediate part, either at the 
time or later. 

In speaking of the operation" on scrofulous tumors of the neck he 
says : " The tumor must be removed little by little, great care being 
taken not to cut the blood-vessels or the nerves. If a vein or an artery 
is injured, so that the hemorrhage is troublesome or hinders the operation, 
put into the wound some vitriol in powder or some kind of haemostatic 
powder ; bandage the wound, and leave it until the inflammation lessens 
and the wound tends to putrefaction. Then the hemorrhage will cease 
and you may go on to complete your operation." 

He says : " The ancients have spoken of opening the trachea, but 
I have not known any one in our country who has practised this opera- 
tion. If the operation has been decided upon, the incision should be 
made below the third or fourth ring of the trachea transversely between 
the two rings, so as not to injure the cartilages, but only to divide the 
membrane between the rings. I have seen a slave who had cut his 
throat with a knife. On examining the wound a little blood escaped, but 
I found that neither the jugular vein nor the artery had been injured. 
The air came out by the wound ; I dressed it and he was cured, and 
only a little hoarseness of voice followed. I feel, therefore, authorized 
to say that incision of the trachea is without danger." 

In speaking of aneurism he says: "As to the tumors which result 
from the enlargement of the calibre of the artery, a longitudinal incision 
should be made over the skin. Enlarge the opening with hooks, dissect 
the artery, free it from the membranes which surround it, and lay it 
completely bare ; then introduce below it a needle with a double thread 
and make a double ligature of the vessel, as we have recommended for 
the excision of the temporal artery ; then plunge a knife into the part 
of the vessel included between the two ligatures, and press out all the 
blood which is contained therein, until the tumor has disappeared, 
employing after this the treatment which leads to suppuration until 



38 THE HISTORY AND LITERATURE OF SURGERY. 

the ligatures fall." It will be seen that this is a copy of the description 
of the operation of Antyllus. 

In speaking of the removal of certain fungoid abdominal tumors 
resembling mushrooms he directs that a leaden wire be used to strangle 
the growths, the wire being drawn tighter and tighter from day to day, 
so as gradually to penetrate the root of the tumor, so that it may fail 
without difficulty. He says : " Eefrain from attempting to excise tumors 
which are of a livid color, of slight sensibility, and of an irregular aspect, 
for these tumors are cancerous." Elsewhere he says : " If the cancer is 
situated in a region from which it can be entirely removed, such as the 
breast, the thigh, etc., and, above all, if it has had its commencement 
little developed, one may operate on it ; if, on the contrary, it is large 
and old, it is necessary to refrain. For my part, I have never been able 
to cure a single one. I have never seen any one who has succeeded." 

His description of the operation of the removal of calculus of the 
bladder is substantially the same as that given by Celsus. 

In the case of a vesical calculus in a woman he says that if you are 
obliged to treat such a case, you must find a woman with some skill in 
medicine, but there are very few of them. If you cannot find such, it 
is necessary to take a midwife, or, at all events, a woman who knows a 
little something about the matter. This woman is to perform the opera- 
tion under the direction of the surgeon, according to the method which 
he gives in detail. 

While the arts and sciences were more or less prosperous and pro- 
gressive in the countries under Mohammedan rule, and especially in 
Spain, throughout the rest of Europe medicine was substantially in the 
condition in which it exists in barbarous tribes. AYith the rise of the 
monkish orders, and especially of the order of St. Benedict, the priests 
became the practitioners, and all progress or improvement was practi- 
cally at an end. Relics, exorcisms, and prayers were more and more 
relied upon ; the teachings of Hippocrates and Galen were for the most 
part forgotten. The great majority of the monks read nothing but 
simple formularies and receipt-books. The kings and the great nobles, 
including some of the bishops, resorted to Hebrew physicians, who 
during the tenth and eleventh centuries were almost the only persons 
who possessed medical learning or who wrote upon medical subjects. A 
Jewish physician in those days was a sort of contraband luxury. On 
account of his religion he could only be possessed by those who had suf- 
ficient power to protect him from mobs and monks ; but both Catholic 
and Mohammedan rulers resorted to him when anything like scientific 
knowledge was required. Eabbi Isaac was the medical adviser of Pope 
Boniface VIII., and the physician of Saladin was Eabbi Ben-Moosa 
better known as Moses Maimonides, who was one of the most celebrated 
authors of his race and time (1136-1209 A. d.). It should be noted that 
the preference was for Jewish physicians as being Jews. For instance 
Francis I., being sick, wrote to Charles V. for an Israelite who was 
an imperial physician. Accordingly, the doctor was sent to Paris but 
Francis, finding that he had been converted to Christianity, lost all con- 
fidence in his skill and advice, and applied to Solyman ILJ who sent him 
a true, original, hardened Jew, following whose advice he drank asses' 
milk and recovered. 



THE HISTORY AND LITERATURE OF SURGERY. 39 

Surgery was for the most part abandoned to barbers, bathers, and 
seventh sons, and fell into disrepute. These barbers and bathers were 
considered to be of inferior caste, and an artisan Avould not take an ap- 
prentice of a family of barbers, bath-keepers, shepherds, or butchers. 
The operators were often peripatetic and were subdivided into specialists. 
For instance, one operated for hernia, another for calculus, a third for 
cataract, etc., the knowledge being handed down from father to son, as 
among the Greeks. 

There were no European writers upon, or teachers of, surgery until 
the time of the rise of the universities in Italy in the thirteenth century. 
The School of Salernum was probably in existence in the ninth century, 
the ancient legend being that it was founded by four men — a Jew, a 
Greek, an Arab, and an Italian — each of whom gave lessons in his own 
language. 

About the year 1060 A. D. there came to this school a certain Constan- 
tine, generally known as " Constantinus Africanus." Constantine was a 
native of Carthage, and had studied in Arabia, India, and Egypt, after 
which he travelled extensively for over thirty years. Returning to Car- 
thage and bringing with him copies of all the works of the Greek and 
Arab writers which he had been able to obtain in his travels, he fell under 
the suspicion of knowing more than it was at that time considered proper 
for any man to know, and it was with some difficulty that he escaped the 
punishment then in vogue for such criminals. He fled for refuge to 
Salernum, where he was received with honors, which, however, he put 
aside, and retired to the neighboring monasteiy of Monte Casino, where 
he spent the rest of his life in translating and annotating the medical 
works which he had collected. These translations became the text-books 
of the Salernitan doctors, and in the next century the school was resorted 
to from all parts of Europe by those who had heard of these long-lost 
and forgotten treasures of learning, which at that time were far in advance 
of the existing knowledge of the ordinary practitioners.' 

The doctrines of the school became more and more Arabic, and it had 
lost its importance in the fourteenth century, having been superseded by 
the schools of Naples, Bologna, Paris, and Montpellier. 

At the beginning of the thirteenth century comes the first writer on 
surgery in the West — namely, ' Roger of Parma, whose work was first 
printed at Venice in 1490, and is included in several editions of the 
works of Guy de Chauliac. The Surgery of Roger is substantially the 
sixth book of Paul of ^gina. Following him came his pupil and com- 
mentator, Roland, who was also of Parma. His work is a copy of that 
of Roger, with notes and some references to Hippocrates, Galen, and 
Avicenna which do not appear in the work of his master. 

The story of the Four Masters, as told by Quesnay, is a romantic 
one — L e. that they devoted their lives to the care of the sick poor in 
Paris, their residence being a sort of surgical dispensary ; that they made 
many discoveries and improvements which they described in a book 
which was known to Guy de Chauliac, but has been lost ; etc. Several 

' For a full and interesting discussion of the writings of Constantine and the authors 
copied and abridged by him, consult " Constantinus Africanus und seine Arabischen 
Quellen," von M. Steinschneider, Archiv /. ■path. Anat. (Virchow), 1866, vol. xxxvii. p. 
361. 



40 THE HISTORY AND LITERATURE OF SURGERY. 

manuscript copies of this work are now known to exist, and in 1859 one 
of these was edited by Daremberg and published. 

The history of surgery in Europe thus begins in Italy at Salernum, 
and in Bologna, where Hugo of Lucca flourished during the first half 
of the thirteenth century, and was followed by William of Salicet. 
We have no writings from Hugo, but the Cyrurgia of William remains 
to us. The first edition of the original Latin was published at Placentia 
in 1476, and this, with other editions, including French translations 
(Lyons, 1492, and Paris, 1507) and an Italian translation published at 
Milan in 1504, is in the Army Medical Library at Washington. 

William of Salicet was the most celebrated surgeon of his century ; 
he was an educated physician, who gives some of his own observations 
and his own conclusions, hardly citing previous authors, although it is 
evident that he was familiar with the works of Avicenna and of Galen. 
It is a pity that the Cyrurgia has never been translated into English. 

The next noted surgeon of this period is Lanfranc of Milan, a pupil 
of William of Salicet, to whom he refers as his "master of goodly 
memory." Lanfranc also received a university education, and was a 
physician as well as a surgeon. Political troubles having caused his 
banishment from Milan, he went first to Lyons, where he wrote an 
epitome of surgery, and finally in 1295 to Paris, where he gave, at 
the School of Medicine, a course of lectures which were probably em- 
bodied in his great Surgery, which he completed in 1296. He was thus 
the introducer of the new Italian ideas into France. His large work 
was first published at Venice in 1490 under the title Practioa quce dis- 
citur ars eompleta totius Chirurgice." In the same year a French trans- 
lation by Guillaume Yvoire was published at Lyons, and of this there is 
a copy in the Bibliotheque Nationale at Paris. 

After Lanfranc came Henri de Mondeville, a native of Normandy, 
of whose early life nothing is known except that he studied at Mont- 
pellier, and at Paris under Jean Pitard, who will be referred to hereafter, 
and that he was one of the four surgeons of the court of Philip the Fair 
prior to 1301. In 1306, at the request, as he says, of Bernard de Gordon, 
a distinguished professor of Montpellier, he began to write, and to read 
to his numerous pupils, a systematic treatise on surgery, which he did 
not complete, although he lived until about 1318. This treatise, of 
which several manuscripts exist, was finally edited and printed bv Dr. 
Julius Leopold Pagel of Berlin in 1892, forming an octavo volume of 
660 pages having the title of Die Chirurgie des Heinrich von Mondeville 
(Hermondaville), etc., and has been translated into French and published 
in 1893 by Professor Nicaise of the Faculty of Medicine of Paris. His 
practice is much the same as that of Lanfranc, and of his successor, Guy 
de Chauliac, who often quotes him. He describes the method of ligating 
a wounded artery, recommending a peculiar kind of slipknot, but says 
nothing of ligating the vessel in amputations, and refers to the use of the 
anaesthetic sponge described by Guy. 

Here may also be mentioned the Surgery of Master Jean Yperman 
a native of Flanders, who was born in the latter part of the thirteenth 
century and studied under Lanfranc in Paris. The manuscript of his 
book, dated 1351, was first described, and in part published by Dr. 
Carolus in the Annates de la Soei&te de Midecine de Gand (vol. xxxii. 



THE HISTORY AND LITERATURE OF SURGERY. 41 

1854) ; also published separately as a reprint. He refers to Roger and 
Roland and the Four Masters, and frequently to Lanfranc, beyond whose 
teachings he seldom ventures to go, although he does give some cases of 
his own. 

The great French surgical author of the fourteenth century was Gui 
(or, as it is more usually given, Guy) de Chauliac, " Guide de Chauliaco," 
born about 1300 A. D. He received the university training of the cler- 
ical profession and studied medicine at Paris, after which he continued 
this study at Montpellier and Bologna, so that he had the benefit of the 
three greatest universities of that time — Paris being especially celebrated 
for its surgery after Lanfranc had reached it ; Montpellier being the 
centre for medicine ; and Bologna for anatomy, of which Bertrucius was 
then professor. After extensive travels, and practice in diiferent places, 
including Lyons and Montpellier, he went to Avignon and became the 
physician of Pope Clement VI. and of his successors, Innocent VI. and 
Urban V. His chief literary work was his Chintrgia, written at Avi- 
gnon in 1363, and first published at Lyons by Nicholas Panis in 1478. 

The " Great Surgery " begins with a special introductory chapter, 
the chapitre singuUer. He says : " Up to the time of Avicenna all 
writers were both physicians and surgeons (?'. e. well-educated men), but 
since that time, either because of the fastidiousness or the excessive 
occupation of the clerics, surgery has become a separate branch and has 
fallen into the hands of the mechanics. 

" The sects which have existed in my time among the operators of 
this art, besides the two general ones of the Logicians and the Empirics, 
have been five. 

" The first was the school of Roger, Roland, and the Four Masters, 
who treat all wounds and abscesses alike with cataplasms and poultices, 
on the ground of the fifth aphorism, ' Lax things are good, and crude 
bad.' 

" The second was the school of Bruno and Theodoric, which treated 
all wounds alike with wine, basing their practice exclusively upon the 
maxim, ' The dry is nearest to that which is sound, and the moist to that 
which is not sound.' 

" The third sect was that of William of Salicet and of Lanfranc, who 
wished to pursue the middle course, covering and dressing all wounds 
with ointments and soft plasters, founding this practice on the fourteenth 
maxim of the Therapeutics — that curation has one sole method ; that the 
treatment should be gentle and without pain. 

"The fourth sect is composed of all the military men, or German 
chevaliers and others following the army, who, with conjurations and 
potions, oil, wool, and cabbage-leaves, dress all wounds, basing their 
practice on the maxim that God has given his virtue to herbs and to 
stones. 

" The fifth sect is of women and of many fools, who refer the sick of 
all diseases to the saints solely, saying, ' Le Seigneur me I'a donnee ainsi 
qu'il luy a plU ; le Seigneur me I'ostera quancl il luy plaira ; le nom du 
Seigneur soit benit. Amen.' " 

It will be seen that Guy is quite trenchant in his summaries and crit- 
icisms, which, however, appear to be on the whole fair and justifiable. 
The teachings of Guy were the chief authority in surgical matters 



42 THE HISTORY AND LITERATURE OF SURGERY. 

for over two hundred years, and were the basis of numerous abstracts, 
compends, and commentaries. He contributed little that was original, 
although he gives some of his own observations. Follin remarks that a 
sort of canulated sound, the dressing of ulcers with sheet lead, and some 
peculiarly-shaped cauteries are his chief inventions ; but his book is one 
of the monuments of surgical literature. 

The Sermo Septimus de cyrurgia et de deooratione of Nicholas Falcu- 
tius, of which the Washington Library has an edition printed at Florence 
in 1507, is a huge folio volume compiled from the works of Arab writers, 
with references to Roger and Eoland, but not to Guy de Chauliac, so far 
as I have found. His formula of words is " Dixit Haly," or " Avicen," 
or " Albucasis," without attempt at comment. 

In the days of Lanfranc and Guy de Chauliac surgery in Western 
Europe was distinct from medicine, and was looked upon as a trade or 
handicraft degrading to and unworthy of physicians, who claimed to 
belong to the nobility. The physicians were of the priestly class and 
abhorred the shedding of blood, and their traditions were adhered to long 
after medical teaching in the universities had passed into the hands of 
laymen. The barbers were the ordinary surgical operators, and the reason 
for this is given by Dr. Gardner ' as follows : " The monks, as all the 
world knows, required to have their heads regularly shaved, but it is not 
by any means so well known that they had to be bled at stated periods. 
Minuius est was the form of words descriptive of one who had undergone 
the operation, the meaning being that he had been minutus sanguine — 
i. e. deprived of blood. In the monastery of St. Victor at Paris there 
was an order which prescribed such minution five times a year : ' Prima, 
est Septembri ; secunda, ante Adventum ; tertia, ante Quadrigesimum ; 
quarta, post Pascha ; quinta, post Pentacosta.' The monks, therefore, 
required to have about them those who could both shave and bleed, and 
it was very natural that they should prefer that one and the same person 
should perform both these operations." 

In France, however, at an early date there were a few persons whose 
business was the performance of surgical operations, and who were not 
ordinary barbers, although they may have served an apprenticeship as 
such. The Corporation of Barbers in the middle of the thirteenth cen- 
tury was divided into two classes — the ordinary or lay barbers, afterward 
known as " barber surgeons " or " surgeons of the short robe," and the 
" clerk barbers " or " surgeon barbers," " the surgeons of St. C6me " or 
" surgeons of the long robe ; " and these last sought to be independent 
of the ordinary barbers, to monopolize surgical operations, and to raise 
their association from the position of a trade guild to that of a profes- 
sional organization. The Guild of the Surgeon Barbers was organized in 
1268 by an order of the provost of Paris, selecting six surgeons who 
were to examine and license those who wished to practise, more especially 
the barbers. Possibly one of these masters was the celebrated Jean Pitard 
but if so he must have been very young, for he was still living in 1326. 
In 1311, Pitard obtained a decree from King Philip the Fair in which 
after reciting that all sorts of quacks are infesting the city, it is ordered 
that " no male or female shall practise surgery in Paris who has not been 

^ Gardner (John) : Sketch of the Early History of the Medical Profession in EdinburnL 
Edinb., 1864, p. 6. ^ ^ 



THE HISTORY AND LITERATURE OF SURGERY. 43 

examined by our sworn surgeons of Paris named and called together for 
that purpose by Jean Pitard, our sworn surgeon of the Ch&telet, or his 
successors." 

It was evidently impossible to enforce this order, for it was repeated 
in 1352, and again in 1364, with penalties of fines on the erring barbers, 
half of the fines to go to the surgeons' guild, the Brotherhood of St. Come. 
The organization of this brotherhood was by no means pleasing to the 
medical faculty, the members of which desired to retain control of all 
branches of the art, and discredited surgery as a mere mechanical handi- 
craft only to be exercised under the direction of a physician, whose dig- 
nity forbade him to soil his hands. The statutes of the faculty in 1350 
require the candidates to make oath that they will not practise surgery 
in the sense of performing operations or making applications by the 
hands, including the treatment of five classes of alFections — viz. wounds, 
ulcers, fractures, dislocations, and tumors. 

The lay barbers were employed by the physicians, and also sometimes 
as assistants by the surgeons, and at last, in 1372, the barber of the king, 
being the master of the guild of barbers by virtue of his position, induced 
Charles V. to issue an edict which permitted them to treat wounds and 
sores and forbade the surgeons to interfere with them. The relative 
standing in the eyes of the public of the three kinds of practitioners — 
viz. the physicians, the surgeons, and the barbers — may be inferred from 
an order issued during an epidemic of the pest in 1383, which directed 
that there shall be selected to visit the sick four physicians, two sur- 
geons, and six barbers, and the fees of the doctors shall be three hundred 
livres, of the surgeons one hundred and twenty livres, and of the barbers 
eighty livres. 

The so-called College of Surgeons of Paris was not in the least a 
surgical school or an association for mutual discussion and improvement : 
it was purely a trade guild, and the students were simply apprentices to 
the master surgeons, becoming, after 1370, bachelors, licentiates, and 
finally masters. The surgeons had a free dispensary, where they treated 
the poor once a week, and perhaps the apprentices saw there something 
of the practice of other masters besides their own. 

The medical faculty, thinking that its rights, privileges, and monopoly 
of treating the sick were being encroached upon by the surgeons, 
encouraged the barbers in their controversies, and as one means of 
doing this undertook to teach them anatomy. As the barbers did not 
understand Latin, which was the only dignified and proper language to 
be used in teaching in those days, a compromise was necessary, and this 
was effected partly by the use of a sort of dog-Latin, of French words 
with Latin terminations, and partly by reading Guy de Chauliac in Latin, 
but with comments in French, while the assistant barber made the 
incisions in the cadaver and pointed out the parts as the reader named 
them. In 1505 the barbers came more formally under the protection 
and jurisdiction of the faculty, and assumed the name of the Guild of 
the Barber Surgeons, and a few years later the surgeons of the long 
robe, having opposed this movement with very little success, and having 
failed to become a separate faculty in the university, submitted to also 
receive instructions from the physicians. Almost all the medical ofi&cers 
attached to the French armies came from the Corporation of Barber 



44 TSE HISTORY AND LITEBATUBE OF SURGERY. 

Surgeons, and finally one of them, Ambrose Par^, acquired so much 
reputation and influence as to considerably increase the respectability 
and standing of the guild. As a sample of surgical associations in the 
provinces we may take the surgeons of Bordeaux, who in 1519 fornied 
a society composed of Ujaunes (yellow beaks or young birds — i.e. 
aspirants) and companions. They had a password and special secrets ; 
instruction was given in the winter at 5 A. M. in the form of commen- 
taries on Guy de Chauliac, and in the course of one hundred and sixty- 
nine years five bodies were dissected.^ 

There is little of importance in the history of surgery during the 
next hundred years after the death of Guy de Chauliac. _ Peter of 
Argelata, lecturer on surgery at Bologna about the beginning of the 
fifteenth century and dying in 1423, was the principal surgeon of his 
time. His six books on surgery, edited by Moretus, first published at 
Venice in 1480, are largely derived from Paulus and Guy. He was an 
operator as well as a theoretical teacher, performed lithotomy and her- 
niotomy, embalmed Pope Alexander VI., practised craniotomy of the 
foetus in difficult labors, etc. A copy of his books was annotated on 
the margins by Marcellus Cumanus, a surgeon in the Venetian army 
in 1495, and these observations were finally published by Velschius 
(G. H.) in his Sylloge Curationum (Aug. Vindel., 1668). Cumanus 
found nothing in Argelata about the treatment of gunshot wounds, and 
he noted a formula for this purpose consisting of a mixture of oil of 
roses, galbanum, and asafoetida, to be applied hot. 

Gunpowder was used in Avarfare at least as early as 1338 ; the English 
employed it at the battle of Crecy in 1346, but it was a long time before 
any surgeon published an account of gunshot injuries and their treatment. 
The first Italian surgeon to do this was John de Vigo (1460-1 52-), sur- 
geon of Pope Julius II. in 1503, whose Practioa in Arte Chirurgioa 
Copiosa was first published at Rome in 1514. This' book had twenty- 
one editions in thirty years, and was translated into Italian, French, 
English, Spanish, Dutch, German, and Portuguese. The great success 
of the book was due partly to the fact that it was the first complete 
system of surgery issued after that of Guy de Chauliac, partly to the 
fact that it contained an account of gunshot wounds and a section on the 
new disease, syphilis, and also, probaljly, to a considerable degree, because 
it was a book which specially suited a practitioner who knew nothing of 
anatomy and feared or disliked to make use of the knife. It is essen- 
tially a surgery of plasters, ointments, and embrocations, and the name 
of the author is best known to-day in connection with the " emplastrum 
de Vigo." 

The part relating to gunshot wounds is brief. He says they are con- 
tused and burned, and therefore need moist applications, but that they 
are also poisoned by the powder, and therefore need desiccation ; hence 
they are hard to cure. They are to be cauterized with the actual cautery 
or with boiling oil of elder, " for cauterization kepeth the wounde from 
putrefyinge." 

His chapter on syphilis begins as follows (I use the English transla- 
tion of 1543): "In the yeare of our Lord 1494, in the moneth of 
December, when Charles the Frenche kynge toke hys jorney into the 
' Sous (G.) : Bordmux medicale, 1877, p. 49. 



THE HISTORY AND LITERATURE OF SURGERY. 45 

partes of Ytaly to recover the kyngdome of Naples, there appeared 
a certaine dysease throughout al Ytaly of unknowen nature, which 
sondre nations hath called by sondry names. The French men call 
it the dysease of Naples, because the souldyours brought it from thence 
into France. The Neapolitanes call it the Frenche dysease." 

Controversies as to whether syphilis existed prior to the fifteenth cen- 
tury have been many, and the literature on the subject is voluminous ; 
but no positive and convincing proofs of such existence have yet been 
found, although it is probable that it did occur before that time. One 
of the theories of its origin, advanced first by Leonard Schmaus in the 
preface to his little pamphlet, Luoubratiunoula de morho gallico et cura 
ejus noi-iter reperta cum ligno indioo (sm. 4°, Aug. Vindel., 1518), is that 
it was brought from the West Indies by the sailors who returned with 
Columbus after his first voyage, and attempts have been made to furnish 
positive evidence of this from human bones showing evidence of disease, 
and antedating the Columbian discovery ; but none of these have been 
convincing to skilled pathologists. Schmaus says in his preface that he 
learned of its American origin from merchants and sea-captains ; but it 
is probable that this idea was first suggested by the use of guaiacum in 
this disease. Guaiacum came from America, and it was a common idea 
that the bane and the antidote belonged together and were to be found 
in the same vicinity. It is certain that the disease existed in America 
soon after the second voyage of Columbus. 

After John de Vigo came Alexander Benedictus (145?-1525), who was 
professor of anatomy at Padua, an army surgeon, and who operated for 
hernia and calculus. He is the author of treatises on anatomy and on 
the pest, and of De omnium a vertice ad plantam morborum signis, 
etc. (Venice, 1535; Basil, 1594), which contains his surgical recom- 
mendations. 

Jacobus Berengarius Carpensis (147 ?— 1550), professor in Bologna, Avas 
the author of a celebrated treatise, Tractatus de fractura calvariae seu 
cranei (Bologna, 1518, quarto), of which a number of editions were 
published. This also contains a few remarks on the treatment of gun- 
shot wounds, which he supposed to be burned or more or less poisoned. 
He acquired a great fortune at Rome by his treatment of sy^ihilis with 
mercurial inunctions, of which he is reported to have been the inventor. 

Alfonso Ferrius (1500- ?) of Naples, the physician of Pope Paul 
III., wrote De Sclopetorum sive ArcMbusorum Yulneribus, libri tres 
(Rome, 1552, quarto), in which he maintains that gunshot wounds are 
poisoned and must be treated accordingly. 

Bartholomseus Maggius (1516-62) of Bologna wrote De Vulnerum 
Sclopetorum et bombardorum globulis illatorum, etc. (Bologna, 1552, 
quarto), of which there were numerous later editions. 

Leonardo Botallo (1530- ?) wrote De Curandis Vulneribus Sclope- 
torum (Lyons, 1580, octavo), in which he opposed the views of De Vigo 
and Ferrius as to the poisoned condition of gunshot wounds. 

Joh. F. Rota, who lived in the middle of the sixteenth century, wrote 
De bellicorum tormentorum vulnerum natura et curatione liber (Bologna, 
1555, quarto). 

One of the wisest of the Italian surgeons of this period appears to 
have been Michael Angelo Blondus (Biondi) (1497-15?) whose little 



46 THE HISTORY AND LITERATURE OF SURGERY. 

treatise De partihus ictu sectis, first published in 1542, and which is 
contained in the Gesner Collection and also in Uffenbach's Thesaurus, 
strongly urges the use of simple water and wetted lint in the dressing 
of wounds. Nevertheless, he was a partisan of the ancients, and two 
of his sayings have become historical as illustrating the university spirit 
of the age— viz. " It is more honorable to err with Galen and Avicenna 
than to acquire glory with others ;" and, " It is better to die by a regular 
physician than to live by a quack." 

One of the most celebrated Italian surgeons of the sixteenth century 
was Gaspar Tagliacozzi, better known as Tagliacotius (1546-99), who 
was professor of anatomy and surgery in the University of Bologna, and 
wrote the first special treatise on plastic surgery, and more particularly 
on the operation of rhinoplasty, with which his name is especially asso- 
ciated. The title of his book is Be Curtorum Ghirurgia per insitionem, 
libri duo, of which two editions were published at Venice in 1597. One 
of these, a large folio published by Gaspar Bindonus, is celebrated for 
the beauty of its plates, the quality of the paper, and its typography, 
being a splendid specimen of book-making ; the other edition of the 
same date and place, published by Robert Meiettus, is also a folio, but 
a much poorer specimen of the printer's and engraver's art. There is 
also a small octavo edition of Frankfort (1598), and one was published 
in Berlin so late as 1831. He does not name the person from Avhom he 
had learned his method, but it was probably from some one of the Incisors 
of his day who had acquired his knowledge from a pupil of one of the 
Sicilian Brancas, who were celebrated for operations of this kind in the 
middle of the fifteenth century. The elder Branca took his flaps for a 
new nose from the skin of the face, being the Indian method ; his son 
made use of the skin of the arm, and extended the method to repair of 
mutilated lips and ears, as we are informed by Bartholomeo Fazia. 

The first notice of Tagliacozzi's method is given by H. Mercurialis 
in his -De deoorafdone liber (4°, Venet., 1585, fol. 23). Two of his 
pupils describe the methods and the results obtained, and acquired 
repute by their performance of the operation — viz. Thomas Fienus of 
Antwerp, and Jo. Bapt. Cortesius, who succeeded Tagliacozzi as pro- 
fessor at Bologna; but the practice fell into disuse among surgeons, 
and little was heard of it until the beginning of the nineteenth century. 
A curious use of plastic surgery is mentioned by Fortunatus Licetus— 
viz. the making of double monsters for show purposes by grafting two 
boys together by the back, nates, or arms, upon which he says : " Aver- 
runcet Deus e severe puniant principes tales sicophantes." Victor Hugo 
refers to the work of these "monster-makers" in his L' Homme qui rit. 

Marianus Sanctus Barolitanus (1490-154?), a native of Naples and 
a special pupil of John de Vigo, wrote a treatise entitled Compendium 
in Chyrurgia Utilissimum Volentibus ipsas exereere, which was first pub- 
lished at Rome in 1516, and subsequently appeared in connection with 
the works of De Vigo. It is also in the Gesner Collection of 1555. 
Neither Haller nor Malgaigne knew the date of the first edition, which 
is probably rare. The copy in the Washington Library is a small quarto 
of fifty leaves, unnumbered and unpaged, and is a fine specimen of black- 
letter printing. It contains three small rude figures of cauterizino- irons 
and the last nine pages are occupied with his Tractatus de Capite. Mari- 



THE HISTORY AND LITERATURE OF SURGERY. 47 

anus Sanctus is best known by his treatise De Lapide ex vesica -per incis- 
ionem extrahenda, in which was, for the first time, published the method 
of John de Romanes for lithotomy with a grooved staff, upon which an 
incision was made into the membranous portion of the urethra, after which 
instruments were introduced to dilate or rupture the prostatic portion. 
This is known as " the method with the great apparatus," from the num- 
ber of instruments required, and also as the " Marian operation," from 
the name of the person who first published the description. The first 
edition of this treatise appeared at Venice in 1535. It is contained in 
the Gesner Collection of 1555 and in Uffenbach's Thesaurus of 1610. 

The " Gesner Collection," also known as the " Geneva Collection," 
is a beautifully printed folio with the title Chirurgia. De ehirurgia 
soriptores optimi quique veteres et reoentiores, etc. (Tiguri, 1555). It was 
edited by Conrad Gesner, and contains the principal surgical works of 
Tagaultius, Hollerius, Marianus Sanctus, Bologninus, Blondus, Maggius, 
Ferrius, Langius, and others, forming a valuable book of reference. 

The first collections of the works of different writers on surgery were 
published at Venice, the first being a small volume issued in 1490, and 
again in 1497, containing the Chirurgia parva of Guy, the Surgery of 
Albucasis, and the commentary of Bertapaglia on Avicenna. A much 
more complete collection is the Venice folio of 1498, which contains the 
works of Guy de Chauliac, Brunus, Theodoricus, Lanfranc, Roger, and 
Bertapaglia. Of this the Venice editions of 1499 and 1519 are in the 
Washington Library; also the edition of 1546, which is the best and 
contains also the treatises of Roland and of William of Salicet. 

From very early times there were to be found throughout Western 
Europe — in France, in Italy, in Germany, and in England — a certain 
number of surgical practitioners known to the writers of that time as 
" The Cutters " or " Incisors." Those who operated for lithotomy, her- 
nia, etc. were of the first class. They travelled about from place to 
place, and maintained more or less secrecy as to their methods, which 
were held as a special family property, being handed down from father 
to son. Among these may be mentioned the two Brancas, to whom 
reference has been made in speaking of Tagliacozzi. 

Another group of these travelling operators was known under the 
name of Norsini. These devoted themselves principally to operations 
for hernia and to lithotomy. Fabrice d'Aquapendente mentions Horace 
of Norsia as a skilled operator in hernia. Sylvaticus in 1601 complains 
that the operation of lithotomy was abandoned to ignorant persons, like 
the Norsini. In 1633, Cortesi writes that at Messina he had seen Ulysses 
of Norsia treat hernia by the application of caustic, followed by incision 
of the eschar; and still later, in 1672, Bernardino Genga says that the 
Norsini had some experience in the treatment of diseases of the urinary 
organs. 

To this class of Cutters belongs probably the unknown surgeon men- 
tioned by Senarega, who in his history of Genoa says that there died 
there in 1510 a surgeon very skilled in removing calculi. He intro- 
duced into the penis an iron rod, which entered the body until it met 
the stone which he was seeking, and which he then removed by a perineal 
incision. It is supposed by some that this unknown Genoese taught 
his method to John de Romanes of Cremona, who is ordinarily credited 



48 THE HISTORY AND LITERATURE OF SURGERY. 

with the invention of the grooved staff for lithotomy, and who taught 
his method to his assistant, Marianus Sanctus. 

The most famous of the Incisors was Pierre Franco, a native of 
Provence, born about 1500, who operated in Provence, Burgundy, and 
Switzerland, finally settling in Lausanne for a considerable period, and 
in 1561 living at Orenge. His Petit trait& contenant une des parties 
prinoipalles de ohirurgie laquelle les ehirurgiens herni^res exereent was 
published at Lyons in 1556. In this he describes and figures the 
"Algalie" sound for detecting stone in the bladder; says that the 
calculus is sometimes encysted so that it cannot be felt by the sound ; 
describes the old operation of " cutting on the gripe," which he says he 
formerly used ; the operation with a grooved sound and gorget, of both 
of which he gives figures, as also of forceps for crushing the stone if it 
is large ; and concludes that if the stone does not present itself when the 
incision is made, it is best to wait a day or two before attempting to 
remove it. He describes a case in a child ten years old in which, being 
unable to extract the stone through the perineal incision, he performed 
the suprapubic operation, removed the stone, which was the size of an 
egg, and the patient recovered. This is the first recorded case of the 
high operation for stone. He says, however, that he does not advise 
this in ordinary cases. In his description of amputation he does not 
mention the ligature, but advises the actual cautery, and gives figures of 
the sickle-shaped knife, the saw, and the cautery-iron. In 1561 he pub- 
lished at Lyons his Traits des hernies contenant une ample declaration 
de toutes leurs espdoes & autres excellentes parties de la chirurgie, assavoir 
de la pierre, des cataraetes des yeux, & autres maladies, desquelles comme 
la cure est perilleuse, aussi est elle de peu d'hommes bien exercie. This is 
a small octavo of 16 preliminary leaves, 554 pages, and 1 leaf of errata. 
It contains all the matter of the preceding book, and much more, with 
figures of new instruments, and is really a small manual of surgery. 
The part relating to lithotomy remains substantially the same. Next to 
the works of Pare, this is the most valuable contribution of the century 
to surgical literature. 

The history of the Colot family is curious and interesting, but is 
wrongly given by most of the biographers : the best is that given by 
Dr. E. Turner in the Gaz. Hebd. de Med. et de Chir. (Paris, 1880, xvii. 
2' ser. pp. 33, 49). 

The story that a certain Germain Colot, a French surgeon, learned 
the details of the methods of some of the Incisors about 1460, and then 
returning to Paris, operated on an archer who had been condemned to be 
hung, but whose sentence was changed by the king to be operated on by 
Colot, is probably without foundation. The original account, given in 
the Chronique scandaleuse, does not mention the name of the operator 
and Malgaigne says that there is not even a presumption that there ever 
was a surgeon named Germain Colot. 

There was, however, a Laurent Colot or Collot, who lived at Tresnel 
near Troyes, in the middle of the sixteenth century, and who learned 
the method of John de Romanes — or Avliat is called the Marian opera- 
tion — from an itinerant lithotomist named Octavien da Villa. He kept 
the method a secret and had great success, being called to Paris in 1556 
and was appointed lithotomist of the Hotel Dieu. The secret and the 



THE HISTORY AND LITERATURE OF SURGERY. 49 

office remained in the family, the grandson Philippe (1593-1656) being 
called to all parts of Europe to operate. His son Franjois (1630-1706) 
wrote an account of the method, which was published after his death 
under the title TraiU de I' operation de la taille, etc. (Paris, 1727). In it 
he refers to the above-mentioned story about Germain Colot, but does 
not give his name, and asserts that the operation performed on the archer 
was a nephrotomy and not a lithotomy. That the so-called family secret 
could have been preserved until the beginning of the eighteenth century, 
after the publication of the method by Marianus Sanctus in 1535 and by 
Franco in 1556, illustrates the education of the surgeons of those days. 

We now come to an epoch-making surgeon, Ambrose Par6 (1517-90), 
who was apprenticed to a provincial barber when he was about nine 
years old. In 1532 he came to Paris, where he was probably again ap- 
prenticed to a barber surgeon and attended the lectures of the doctor of 
the Faculty of Medicine of Paris, whose business it was to explain to 
the young barber surgeons those parts of the surgery of Guy de Chauliac 
which relate to tumors, wounds, and ulcers. Very soon after his arrival 
at Paris he had the good fortune to obtain a position as resident appren- 
tice and dresser in the great hospital of the Hotel Dieu. Here he had 
opportunities for dissections, for making post-mortem examinations, and 
for the study of disease, of which he was not slow to avail himself. In 
his preface to the reader he says : " You must know that for the space 
of three years I have lived in the Hotel Dieu of Paris, where I had the 
means of seeing and knowing (in consequence of the great variety of 
diseases brought there) all which can be of alteration and disease in the 
human body, and to learn from an infinite number of dead all that can 
be said of anatomy." 

At the end of this service, when he was but nineteen years old, he 
became body-surgeon to Mareschal Monte Jan, and went with him in the 
army which Francis I. opposed to that of Charles V. in the invasion of 
Provence in 1636. Gunshot wounds were supposed to be poisoned, and 
the recognized means of destroying the venom was that prescribed by 
John de Vigo — namely, cauterization by boiling oil. But in one battle 
the supply of oil was insufficient, and our conscientious youth could not 
sleep that night for thinking of the horrible fate that was in store for the 
poor fellows who had not been cauterized. Great was his astonishment 
and delight the next day on finding that those who had not been burnt 
were much more comfortable than those who had been treated secundum 
artem, and that recovery was prompter and more certain in their case. 
But, while Par6 had the sense and the independence to refuse to give 
unnecessary pain, although commanded to do so by the highest surgical 
authority of his day, he could not free himself from the notion that some 
special treatment was required for gunshot wounds, nor accept the plain 
teaching of his own experience. He decided that the best thing to be 
done was to use a secret remedy which was the stock in trade of a certain 
surgeon in Turin, and to learn the composition of this remedy he assidu- 
ously courted the good graces of this surgeon for over two years and a 
half, and finally obtained the secret for a round price, promising not to 
divulge it. It was an oil of puppies, not much different from lard — a 
simple protecting soothing application. No sooner had Par6 learned the 
secret than he hastened to publish it, deliberately breaking his promise 

Vol. I.^ 



60 THE HISTORY AND LITERATURE OF SURGERY. 

on the ground that such an important matter should not be one man's 
privilege. 

The great improvement made by Par6 in surgery was the use of the 
ligature to close bleeding arteries after amputation in place of searing 
them with red-hot irons, as had been done down to his time. 

In the edition of his works published in 1564, Dix livres de Chirurgie, 
he first describes and recommends the application of a ligature to bleed- 
ing vessels in amputations, and abandons the use of the cautery. His 
account is as follows : After alluding to the passage in Galen which 
states that " the vessels must be tied toward their roots, which are the 
liver and the heart, to staunch the great flow of blood," he says : " But 
having many times used this means of closing the veins and arteries in 
recent wounds where there was a hemorrhage, I thought it might also be 
done in amputating a member. Therefore, having conferred with Esti- 
enne de la RiviSre and Frangois llasse, both surgeons at Paris" [in 
later editions the name of Rasse is struck out and in place is read " other 
sworn surgeons of Paris "], " we agreed that we would make the trial 
upon the first patient which offered, although we would have the cau- 
teries all ready to use if the ligature failed." A few days afterward the 
ligature was applied with success in a case of amputation of the leg. 

Pare was a good anatomist, by far the greatest surgeon of his time, 
the confidential friend of four successive kings, and is said to have been 
the only Protestant in Paris who was spared the massacre of St. Bar- 
tholomew, which was due to the direct action of the king. Malgaigne's 
argument against the truth of this story cannot outweigh the direct state- 
ments of Sully and of Brantdme. 

Catherine de Medici one day asked Pare whether he hoped to be 
saved in the next world. " Yes, certes, madame," said he, " because I 
do what I can to be a brave man in this world, and because the merciful 
God understands all languages, and is as well satisfied with a French 
prayer as with a Latin one." 

To properly appreciate the writings of Par6, they should be compared 
with those of other teachers of, or writers on, surgery of his day. His 
treatise upon gunshot wounds may be compared Avith several small trea- 
tises on surgery published in the latter half of the century, thirty or 
forty years after the appearance of his treatise on this subject, and written 
in French for the benefit of the barber surgeons. Take, for example^ the 
TralUe des arcbusades of Joubert, published at Lyons in 1574. Laurens 
Joubert (1529-83) was a distinguished physician of Montpellier, pro- 
fessor of medicine in the university and dean of the faculty. He had 
served in the royal army in the campaign of 1569, where he ought to have 
heard something of Fare's methods of treatment, but he makes no allu- 
sion to them, unless it be where he speaks of the oil of puppies as an 
anodyne. His Surgery is that of John de Vigo, written in a diffuse 
pedantic style, which was probably impressive to the barbers in propor- 
tion to their inability to understand the meaning of his words. At one 
time he was called in as an umpire in an argument between a physician 
(Veyras) and the surgeon of the king of Navarre (Guilhemet) as to 
whether gunshot wounds are contused and should be treated by poultices 
etc. or by desiccatives, as by washing with wine. The arguments on 
both sides and Joubert's decision were published in a curious little book 



THE HISTORY AND LITERATURE OF SURGERY. 51 

entitled TraciU de Chirurgie, contenant vraye mSthode de guerir 'phiyes 
d'ai'quebusade, etc., par M. Jacques Veyras, docteur en Medecine, & M. 
Tannequin Guilhemet, Chirurgien du Roy de Navarre (Lyon, 1581, 8°). 
Joubert's decision was, upon the whole, in favor of the views of the 
physician, as was to be expected. He refers to Pare as " homnie digne 
foy," not with reference to his treatment of wounds, but to his statement 
that bones may be fractured by the wind of a cannon-ball — this being 
precisely one of the points on which Pare was wrong. 

The first teaching in French given to the barbers and surgeons was 
by a physician, Jean Canape of Lyons, physician of Francis L, who in 
the first half of the century gave public lectures to them, and for the 
same purpose translated into French a compend by Guy de Chauliac 
(Lyons, 1538, 12°; also 1563-71), some anatomical treatises of Galen 
(Lyons, 1541), and several other small treatises. 

Pierre Tolet (1502-8?), a surgeon of Lyons, in 1540 published a 
translation into French of the sixth Book of Paulus ^gineta. In his 
prefatory letter to this, addressed to the French surgeons, he refers to 
Jean Canape as a man to whom surgery owes more than to any man who 
has written since Galen. 

In 1570, Jacques Dalechamps, physician and reader in surgery at 
Lyons, published Chirurgie Frattgoise as a manual for the barber sur- 
geons. It consists of the sixth book of Paul of JEgina, Hippocrates on 
fractures and dislocations, and extracts from Celsus, Albucasis, etc., 
with the annotations of Dalechamps, and a brief treatise on operations 
by Jean Girault, master surgeon in Paris. 

In 1583, Esaie le Lievre, surgeon, published a little book entitled 
Offioinne et Jardln de Chirurgie militaire contenant les instrumentz et 
plantes tres necessaires a tous Chirurgiens, etc. The general style of 
this work may be seen in the following sentence : " Nous disons I'har- 
quebuzade on playe faicte par harquebuze ou canom ; estre une affection 
centre nature, portant de foy plusieurs especes d'accidens ; a scavoir 
extreme contusion, combustion, diruption, dilaceratio, concution, frac- 
tion, fracation, puis repercution, abolitions, destructions, extinctions, ou 
mortifications, selon plus ou moings, des espritz tant vitaux, aniraaux, que 
naturels : de laquelle complication assemblee, selon la nature & noblesse 
des parties offensSes, se forme une indisposition tendant a rendre ladite 
partie, consequement tout le subiect en cadaver." 

The Sclopetarius of Quercetanus (Du Chesne) (Lyon, 1576) is a 
worthless book by a notorious charlatan. It was translated into Eng- 
lish and published at London in 1590 by a certain John Hester, who 
offered for sale the Arcana prescribed therein. Care is taken to give 
two sets of remedies — one for the injuries of the common soldiers, the 
other " to be used for the rich." For advertising purposes the same 
John Hester published A Short Discours of the excellent Doctour and 
Knight, maister Leonardo Phioraranti, Bolognese, uppon Chirurgerie 
(London, 1580), advertising at the end that he is prepared to furnish 
various salves, philosophical oils, and other preparations recommended 
in it. Phioravanti explains that " the reason why white of egg is to be 
used in mixing applications for wounds is because the white is that part 
which produces the flesh, the skin, and the feathers of the hen, while 
the yolk engendereth only the intestines. Therefore the white is like 



52 THE mSTOBY AND LITERATURE OF SURGERY. 

unto flesh, and its special business is to produce it." He says also that 
the most perfect remedy for a great flux of blood from a wound is to 
stitch it close, and then take dry human blood-powder and lay it upon 
the wound. This is the same as the mummy of Paracelsus. 

The reference made by Pare as to the value of the instruction which 
he obtained in the Hdtel Dieu is perhaps the first allusion to the import- 
ance of hospitals as a means of furnishing instruction insurgery. Hos- 
pitals had existed since before the Christian era in India, and those in 
Persia under the Nestorians were really used for educational purposes 
in connection with their medical schools. The foundations of many 
European hospices and hospitals date from the tenth and twelfth cen- 
turies, such, for example, as the San Spirito at Rome and St. Bartholo- 
mew's and St. Thomas's in London, some of the impulse to the forming 
of such institutions apparently having come from the need of providing 
them for lepers. 

No surgical instruction appears to have been given in the hospitals 
of the Middle Ages, except that the surgeons connected with them rnay 
have employed some of their apprentices to assist them in the bandaging 
and in the dressing of wounds ; but what we know as " clinical surgery " 
was an affair of much later date. 

Of the immediate pupils and followers of Par6, the most important 
were Pierre Pigray (1533-1613), whose published works are mainly 
abstracts and translations of Parg; and Jacques Guillemeau (1550-1612), 
surgeon of Charles IX., Henry III., and Henry IV., and surgeon of 
the Hotel Dieu, who acquired fame as a writer and teacher in surgery, 
obstetrics, and ophthalmology. His La chirurgie francoise (Paris, 1594, 
folio) was translated into Dutch, and thence into English, and published 
at Dort in 1597 under the title of The French Chirurgerye, forming a 
beautifully printed and illustrated folio, which was much the best work 
on this subject which had then appeared in English. Guillemeau was 
unusually well educated for a surgeon of those days, having studied 
under Riolan as well as under Par6, and he tried to harmonize the 
statements of the latter and those of his opponent, Gourmelin, by saying 
that Galen recommends the cautery in amputation for gangrene, and ap- 
proves the use of the ligature for hemorrhage when there is no corruption. 

Par6 in advising the application of the ligature says it does not 
matter if some other tissue besides the vessel is included in it ; but 
Guillemeau says that a portion of such tissue is to be included : " preuant 
quelque portion de chair ensemble," evidently thinking that this is an 
important feature of the operation. 

His chapter on aneurism contains an account of a case of traumatic 
aneurism at the bend of the elbow in which he applied a single ligature 
above the swelling with success. In this case the aneurism had ruptured, 
and after ligating the artery he opened it further and turned out the 
clots. This one ligature was placed three fingers'-breadth above the 
tumor. Park's description of the operation also refers to the use of but 
one ligature, and not to the operation of Antyllus. 

There were no surgeons of repute in Germany prior to the middle 
of the fifteenth century; they were almost all barbers, who could 
neither read nor write. In 1868 there was for the first time pub- 
lished a manuscript treatise on surgery written in German about 1460 



THE HISTORY AND LITEBATUEE OF SURGERY. 53 

by Heinrich Pfolzprundt, and entitled Bundth-Ertznei. This, the oldest 
German work on surgery at present known, relates mainly to the treat- 
ment of wounds, but it contains a remarkable chapter on the making 
of a nev/ nose from the skin of the arm after the method of Branca. 
There is an allusion to the burning of wounds by powder, but no refer- 
ence is made to lithotomy or to operations for hernia. It gives a receipt 
for a narcotic mixture to be inhaled from a sponge similar to that men- 
tioned by Guy de Chauliac. The first German surgeons of repute whose 
works have come down to us are Hieronymus Brunschwig, and Hans 
von Gersdorif, called Schylhans or Schielhans, both being surgeons at 
Strasburg in the last half of the fifteenth century. Brunschwig was 
born about the middle of the fifteenth century, and published at Stras- 
burg in 1497 a folio volume with the title Dis ist das buck der Cirurgia, 
Hautwirck der Wundartzny von Hyeronimo brunschwig. Of this there 
were eight other editions, the last at Augsburg (1539, quarto). The 
Washington Library has the folio editions of 1508 and 1513 and the 
quarto editions of 1533 and 1539 ; also the English translation of 1525, 
and a Dutch translation in folio printed at Utrecht in 1535. The Eng- 
lish translation is the first book on surgery in English, and its title-page 
is a curiosity in itself. It begins as follows : 

" The noble experyence of the vertuous handy warke of surgeri prac- 
tysyd & compyled by the moost experte Mayster Jherome of Bruyns- 
wyke borne in Straesborowe in Almayne ye whiche hath it fyrst proved 
and trewly founde by his awne dayly exercysynge." 

This title is the work of the unknown translator, who has also given 
a short preface, in which he says that "it is oftentymes sene and dayly 
chaunceth in small townes, borowghs and villages that dyverse people 
hurt or dyseased for lacke of connynge men be taken in hande of them 
that be barbers or yonge maisters to whome this sciens was never dys- 
closed, not thynkynge on the wordes of the olde lernyd men that say, 
It is not wel possible to man that he sholde brynge well to a good end 
the thynge whiche he never or hath but lytell seen." 

Brunschwig's book was the first in which any definite statement is 
made about gunshot wounds, or, as the English translation has it, " of 
woundis shot with a gone whereas the venym of the powder abydyth in." 
To remove the venom he advises to pass a small cord of hair through 
the wound and draw it back and forth, after which a tent is to be placed 
in the wound. 

In amputation he advises either the actual cautery or boiling oil to 
check hemorrhage. He has nothing to say about lithotomy, herniotomy, 
aneurism, or tumors — the book being, in fact, a treatise on the military 
surgery of those days. It is illustrated with large quaint wood-cuts 
which are among the earliest specimens of the art. Haeser says there 
were two English translations — one published at London, and the other 
at Southwark, but these are the same work. 

Hans von GersdorfF was an army surgeon in 1476-77, and published 
his book, Feldtbuch der Wundtarzney (in folio), at Strasburg in 1517. 
Of this there were eight later editions and translations into Latin and 
Dutch. The "Washington Library contains the first edition, and also 
the Strasburg editions of 1527 and 1540 and the Frankfort edition of 
1551. Gersdorif treats more fully of shot- wounds than does Brunschwig. 



54 THE HISTORY AND LITERATURE OF SURGERY. 

He does not consider them to be poisonous, but gives detailed directions 
for finding and extracting the bullet, with figures of instruments, and 
advises that the powder be removed, after which warm linseed oil is to 
be poured into the wound. He says : " I do not know of any better or 
milder remedy than this, which I have learned from Master Nicolaus, 
called the Maulartzt, surgeon to Duke Sigmund of Austria." If ampu- 
tation becomes necessary, he says : " First of all advise the patient to 
resign himself to God, to confess his sins, to remember the suffermg of 
our Ijord with thanks, and the surgeon the same ; thus will God grant 
him good fortune in his work. And when you will cut him have ready 
by each other all your instruments and apparatus, such as scissors, knife, 
saw^ styptics, bands (lassbendel), bandages, pads, tow, eggs, and what 
belongs to it, so that one follows the other in the order of the operation, 
since there is need of this. And when you are ready to cut let some 
one draw back the skin strongly and tie a band firmly around it, and 
place another band in front so that a space of a finger-breadth be left 
between the two bands that you may cut between them with the knife ; 
then this cut is quite sure, easily made and makes a good stump. AVhen 
you have made the cut take a saw and divide the bone, and then remove 
the band and tell some one to draw the skin over the bone and flesh and 
hold it tight in front ; and you should have a bandage two fingers broad 
and well wetted that it may lie smooth, and with it bandage the thigh 
down to the cut that the flesh may go in front of the bone, and leave it 
thus bound. And you need not fear bleeding if you have done as above 
described. Bind now over the styptic a good thick pad, take the bladder 
of a bull, ox, or hog, one Avhich is strong, cut the neck open so that it will 
go over the pad and stump, and the bladder should be Avet but not too 
soft ; draw it then over all, tie it hard with a band and you need have 
no care about the bleeding." 

The following is the styptic referred to : " Take of imslacked lime 
two ounces, vitriol, alum, each, one ounce, of aloes to be calcined, gall- 
nuts, colophony eacli a quarter of an ounce ; of the residuum in the 
retort when you make aquafortis two and a half ounces, and the white 
hair of tlie belly of a hare or deer chopped up, arid mix all together 

thoroughly. When you use it mix it with white of eggs But if 

an artery rages and will not be staunched then burn it with a cautery." 
Although he used no ligature in amputation, he does advise a double 
ligature on a wounded blood-vessel. He has a chapter on leprosy, but 
says nothing definite about syphilis. The plates in GersdoflfiF's book are 
especially interesting. 

Walter Hermann Ryff was also a Strasburg surgeon of the first 
part of the sixteenth century, and published a number of treatises in 
German, his Gross Chirurgei appearing in 1545, and his Kleiner 
C'hirtirf/i in 1551. This tendency to depart from scholastic methods 
received a strong impulse from the sayings, doings, and writings of 
Philippe Aureole Theophrastus Bombastes de Hohenheim, better known 
as Paracelsus (1493-1541). He was born in the village of Einsiedeln, 
near Zurich, studied medicine with his father, travelled extensivelv 
studied chemistry and alchemy -with Sigisnumd Fugger, and served 
as an army surgeon in campaigns in Italy and the Netherlands. Of 
unbounded self-assurance and having a knowledge of some new reme- 



THE HISTORY AND LITERATURE OF SURGERY. 55 

dies, such as antimony, arsenic, and mercury, he soon acquired a great 
reputation, and in 1526 was appointed professor of medicine in the 
University of Basle. He is characterized by Dalton as " a rampant, 
blatant, boasting, ignorant vagabond, with a face of brass and a tongue 
like a race-horse," and, if the word " ignorant " be omitted, it is a true 
picture. But he was also a sort of genius, in a way a poet ; and, knave and 
charlatan, and in his latter days drunkard, though he was, his doctrines 
were accepted by such men as Frobenius, Erasmus, and Van Helmont, 
and had a powerful influence throughout Europe for a century or more, 
some of his peculiar theories still surviving as the essence of modern 
homceopathy. He wrote or dictated many works, of which the only 
one that need be mentioned here is Der grossen Wu rida rfzney (1536-37), 
of which there were several editions, besides Latin and French transla- 
tions. The second chapter begins as follows : " It is necessary to know 
in the first place what is the efficient cause of the curing of wounds, 
because this may of itself indicate the proper treatment. Know then 
that the human body contains in itself its own proper radical balsam, 
born in it, and with it, and not only the body as a whole contains it, 
but all its parts, such as flesh, bones and nerves, have each its own 

peculiar juice competent to cure wounds It is not the surgeon 

who cures wounds, it is the natural balsam (or juice) in the part itself." 
Hence he inveighs against what he calls " the damnable precept which 
teaches that it is necessary to make wounds suppurate." Elsewhere 
he calls this animal juice " la mumie," but he also meant by this a 
special preparation made from certain parts of the human body — 
something like the animal juices and extracts which have been re- 
cently recommended as remedies, and which are quite Paracelsian in 
character. 

The ideas of Paracelsus were accepted by Felix Wurtz (1514-74) of 
Basle, who studied under RyfF at Nuremberg, and was on terms of inti- 
macy with Paracelsus and with Conrad Gesner, the most learned man 
of his time. He acquired great reputation, and published his Practica 
der Wundarzney in 1563. Of this about fifteen editions appeared during 
the next hundred years, including an English translation by Fox, j)ub- 
lished in 1656. He remarks that "skill in surgery is obtained with 
great painfulness, for it is not gotten with sitting on a cushion at home 
and by reading and writing ; .... it is not enough to be full of talk, 
and to say such and such and write so and so, — a patient is little the 
better for it if the surgeon hath no skill to dress his wounds." The work 
is almost entirely devoted to wounds and fractures and their consequences, 
and contains nothing as to the technique of surgical operations. The 
treatment advocated is in the main simple and sensible. Styptic powders 
are condemned for general use, as is also the cautery to suppress hemor- 
rhage, except in amputation of the thigh. No allusion is made to the 
ligature, and it is not probable tliat he had ever seen the works of Pare. 
He objects to the probing of wounds, declaring that it is folly to feel and 
grope about them, and that some surgeons use the probe merely because 
they have seen it used and to show that they are doing something. Cat- 
aplasms and poultices for fresh wounds are condemned, and the blood 
is not to be washed or squeezed out, " for it is a right flesh glue and 
hasteneth the healing." He often refers to the conservative surgeons 



56 THE HISTORY AND LITERATURE OF SURGERY. 

who say, " Old customs should not be abandoned," and says, " Therefore 
in some places the books of Theophrastus Paracelsus (to whom the best 
and most famous surgeons must give place) are prohibited to be read ; 
but in my simple judgment it is done very foolishly." He objects to 
drawing a cord through a gunshot wound, or to using hot oil, or to 
treating such injuries otherwise than as simple wounds. The third part 
of his book, being on the symptoms and complications of wounds, 
including a description of the wound-fever or pyaemia, is the most 
original and valuable part of the work. 

The instruction of the barber surgeons' apprentices at the end of the 
sixteenth century appears to have been based on the views of Jerome of 
Brunswick, if we may judge from a little manual by Julius Holder, pub- 
lished at Frankfort in 1592, entitled Dialogus, ein Nutzliche und Warh- 
afftige Beschi-eihung eines rechte Wundartzts unnd seiner Meisterschaft. 
This is in the form of questions and answers, Latin terms being curiously 
intermixed with the German. 

Another good specimen of the sort of instruction given to apprentices 
of German barber surgeons in the sixteenth century is the Wundartzney 
zu alien gebrechen des gantzen Leibs, etc. of Joannes Charethanus (or 
Charetanus), of which five editions appeared between 1530 and 1556. 
The edition of 1549, printed at Frankfort, is a small quarto of 20 
leaves, giving directions for bloodletting and tooth-pulling, and various 
formulae for salves and potions. It directs that wounds should be dressed 
twice a day ; that he who is wounded in the head shall not walk about or 
move much ; that he shall avoid perspiring and talking, which inflame 
or disturb the brain and make him insensible ; above all, he shall avoid 
strong wine, which puts him in deadly peril ; likewise the rays of the sun 
and light and heat and indigestible meat and the society of woman, whom 
he shall not even look upon. 

If a large artery is cut or opened, first secure the same carefully with 
a silk thread to stop the bleeding ; then lay on the red powder and cover 
with a red plaster. Let it remain for four days and heal it like other 
wounds. 

The Seventeenth Oentuby. 

The seventeenth century is more remarkable for the advances which 
were made in physics and in physiology than it is for improvements in 
surgery. It was the age of Francis Bacon (1561-1626), of Galileo (1564- 
1642), of Een6 Descartes (1596-1650), of Pascal (1623-62), of Sir Isaac 
Newton (1642-1727), and of Eobert Boyle (1626-91), all of whom had 
a powerful influence in developing the iatro-chemical and iatro-mechan- 
ical theories which prevailed about the end of the century. This was 
also the age of Borelli (1608-79), of Thomas Sydenham (1624-89), 
and, above all, of William Harvey (1578-1657), the pupil of Fabricius 
d'Aquapendente, whose celebrated work, Exercitatio Anatomiea de Motu 
Cordis et Sanguinis, appeared in 1628. 

At, the commencement of this century the most distinguished Italian 
surgeon was Hieronymus Fabricius d'Aquapendente (1537-1619), who 
was a pupil of Fallopius and succeeded him as professor of anatomy at 
Padua. He was the discoverer of the valves of the veins and the teacher 
of Harvey. His principal discoveries and writings relate to anatomy 



THE HISTORY AND LITERATURE OF SURGERY. 57 

and embryology, but he was also professor of surgery, and his Pentateu- 
chos Chirurgicum (Francof., 1582) and his Opera Chirnrgica (Paris, 
1613, in folio, and later editions) were important works of reference 
during the next century. Fabricius was learned and eloquent, and made 
the University of Padua the most important school for anatomy and sur- 
gery in Europe. His surgery is mainly that of Celsus, Paul of iEgina, 
and Albucasis, to whom he gives full credit, carefully noting the sources 
of his quotations. No great advance in the art is due to him, but his 
works contain many accounts of cases and references to the methods of 
other surgeons, making them valuable historically, and they are far more 
interesting as a piece of literature than is the corresponding work of John 
de Vigo. In speaking of wounds of the intestines he refers to animal 
sutures and to the insertion of a piece of the trachea of an animal to 
preserve the lumen of the gut. He describes tracheotomy and urges its 
performance in certain cases, and says that he has seen one case of cancer 
of the breast cured by excision, but has never performed the operation 
himself. 

Next to him came Cesare Magati (1579-1647), who became professor 
at Ferrara in 1612 (or 1621?), and who gained much repute by his book, 
De vara medioatione vulnerum, sen de vulneribus raro tractandis (libri ii., 
Venet., 1616, folio). In this he urged a simpler mode of treating wounds 
than was then fashionable, advising less frequent dressings, condemning 
the use of tents, and maintaining that gunshot wounds are not poisoned. 
His doctrines were specially urged and made prominent by Sancassini in 
the early part of the eighteenth century. 

Marcus Aurelius Severinus (1580-1656), professor at Naples, one of 
the most celebrated teachers of anatomy and surgery of his time, is best 
known by his book De reeondita abseessuum natura (Naples, 1632, 
quarto), of which several later editions were published. 

Giovanni Battista Cortesi (1554-1636), a barber's apprentice, after- 
ward a pupil of Tagliacozzi, whom he succeeded as professor at Bologna, 
published a treatise on wounds of the head in 1632, and a manual of 
surgery in 1633, which are of little interest. 

Gaspar Asellius, the discoverer of the lacteals, in 1623 was professor 
of surgery and anatomy at Pavia, but wrote nothing on surgery. 

Spigelius (1578-1625), a native of Brussels, professor of anatomy and 
surgery at Padua in 1605, was an operator, and is said to have trephined 
the same patient seven times, but there is nothing surgical in his pub- 
lished works. Trephining was a common operation at this time, being 
employed in cases of insanity, of severe headache, and of chronic diseases 
of the eyes, as well as for injuries of the skull. 

Pietro de Marchetti (1589-1673), professor of surgery at Padua, 
published a collection of cases under the title Observationum medico- 
chimrgicarum sylloge (Padua, 1664, and later editions), which is of 
permanent historical value. Among these cases is one of successful 
trephining following a dagger-wound of the head two or three months 
previous, and several cases of the same operation for headache. Here 
also is the celebrated case in which a pig's tail was forced into the anus 
of a prostitute, and was removed by slipping a tube over it. Pietro was 
succeeded in the chair of surgery in 1662 by his son Dominique, wlio 
acquired great fame as a teacher, and is said to have performed nephrot- 



58 THE HISTORY AND LITERATURE OF SURGERY. 

omy successfully without being guided by the presence of any tumefac- 
tion of the part. 

Filippo Masiero, a surgeon of Padua, was the author of the follow- 
ing books: II ehirurgo in prattica, etc. (Venet., 1688, 4to ; 5th ed. 
1749, 8°), II sogtio chirurgioo (Parts I., II., Padua, 1697), and Opere 
chirurgisohe (Padua, 1707). 

Carolus Musitanus, a physician of Naples, published his Chirurgia 
theoretica practica in 1698. Haller styles him " improbabilium histori- 
arum narrator." 

In France there was little progress in surgery until near the end of 
the century. The medical faculty finally triumphed over the surgeons 
by obtaining a decree which united the barbers and the surgeons in one 
corporation, and the College of St. Come was no longer a power in the 
land. Among the French works on surgery of this period may be men- 
tioned Quelques traites des operations de chirurgie, by Jean Girault (Paris, 
1610) ; Observations M^decinales et Chirurgicales, etc., of Gul. Loyseau 
(Bordeaux, 1617) ; Observations iatrochirurgiques of Covillard (Lyon, 
1639) and Le Ckirurgien Optrateur of the same author (1633 ?; 2d 
ed. Lyon, 1640) ; Epistola de laryngotomia of Eene Moreau (Paris, 
1646)"; La Chirurgie Militaire of Leonard Tassin (Nimwegen, 1673); 
Les operations de la chirurgie of J. Bienaise (Paris, 1688); and Traite 
des playes d'arqitebusade of Scipio Abeille (Paris, 1695). 

In i696, M. de la Vauguion, a physician, published a Traite complet 
des operations de chirurgie (8°, Paris), which is the most complete man- 
ual in French prior to that of Dionis, and of the English translation of 
which at least three editions were published (1699, 1707, and 1716). He 
names the tourniquet and describes its application in amputation and 
in the operation for aneurism, and quotes frequently from Fabricius 
Hildanus. 

Nicolas de Blegny (1652-1722), surgeon of the duke of Orleans in 
1683, the founder of the first medical journal, published a treatise on 
venereal diseases in 1673, and a treatise on the treatment of hernia, with 
description of a truss of his invention, in 1676. He is also the author 
of the first city directory. 

Previous to the seventeenth century surgery had made little progress in 
the Netherlands, and there ai'e very few books to be noted. The work of 
Ypermans has already been referred to. Carolus Battus, a surgeon of Dor- 
drecht, published in 1590 his Handtboeck der Chirurgijen, of which there 
were six later editions. He also translated the works of Par6 into Dutch. 

In the middle of this century Holland became celebrated as a centre 
of anatomical and surgical teaching through the labors of Tulp, Bar- 
bette, Van Meekren, Van Home, Van Eoonhuysen, Solingen, Verduyn, 
and others, and the schools of Amsterdam and Leyden began to draw 
students from all parts of Europe. 

Paul Barbette (162 ?-7?), son of a Strasburg surgeon, studied in 
Montpellier and Paris and settled in Amsterdam. He was a voluminous 
writer, and his Chirurgie, first published in Dutch in 1657, passed through 
ten editions and translations, being a popular manual, while his Opera 
omnia, was issued twenty-two times in various languages. He first 
described femoral hernia, suggested laparotomy in intestinal obstruc- 
tion, and extirpation of the spleen, which he performed on doo-s. 



THE HISTORY AND LITERATURE OF SURGERY. 59 

Job Janszoon Van Meekren (?-1666), a native of Amsterdam 
and a pupil of Tulp, was a celebrated operator. His book, Heel at. 
geneeshonstige aanmerJcingen (Amst., 1668), was translated into German 
and Latin. 

Job. van Home (1621-70), professor of anatomy and surgery in 
Leyden, was a distinguisbed teacher, but his writings relate mainly to 
anatomy, his Miorotechne id est brevissima Chirurgiae Metliodus (1663) 
being merely a manual. There is an English translation of this (London, 
1717). 

Hendrik van Roonhuysen (1625-6?), a surgeon of Amsterdam, also 
well known as an obstetrician, published his Geiiees-en Heelkonstige 
aanmerklngen in 1672. He operated for wry-neck and hare-lip, advised 
Csesarean section, removed tumors, and seems to have been specially 
skilled in his art. 

Cornells Solingen (1641-87), a surgeon at the Hague, wrote Mnnucde 
Operatien der Chirurgie (Amst., 1684), which Haller says is full of 
original observations. 

Peter A. Verduyn (162?-?), a surgeon of Amsterdam, is celebrated 
for his treatise on the flap method of amputation. Diss, de nova artuwn 
decurtandorum ratione (Amst., 1696). He seems to have known nothing 
of the similar methods of Lowdham. (See p. 67.) 

Joannes Muys of Arnhem and Leyden published the first two parts 
of his Praxis Chirurgiae rationalis in 1683, and the complete work in 
1695. This contains accounts of one hundred and twenty cases, some 
of which are curious and interesting. 

Fabricius Hildanus (1560-1624) is sometimes called the " Father of 
German Surgery," although this title belongs more properly to Heister. 
He was a Swiss by birth, and for the last twenty years of his life was 
the city physician of Berne. He was a surgeon's apprentice who man- 
aged to acquire a good classical education, and probably obtained good 
practical training under Griffon, a surgeon of Geneva. He travelled 
much, resided for some time at Cologne, and became widely known as 
a bold and skilful operator, and especially as a lithotomist. He was a 
strong opponent of Paracelsus and his friend Wurtz, and was a volu- 
minous writer, but his monographs are, for the most part, of little 
interest, the best being his lAthotomia Vesicae (Basle, 1626), translated 
into English and published at London in 1640. His most important 
publication for readers of the present day is his Observationum et Cura- 
tionum Chirurgicarum Centuriae, in which he relates his experience in 
a large niunber of surgical cases of the most varied character. He 
advised amputation at an early stage in gangrene, and that the incision 
should be made in the sound and not in the decayed flesh. 

He used the cautery, and not the ligature, in wounds of the arteries, 
and devised a number of complicated instruments, none of which are 
of practical interest. His chief influence on surgery was through his 
correspondence with German physicians and surgeons, and through his 
urging upon the German surgeons the necessity for the study of anat- 
omy. His Opera omnia, of which several editions were published, 
appears to have been a favorite book of reference for surgeons for 
many years. 

John Schultes, better known as "Scultetus" (1595-1645), a pupil of 



60 THE HISTORY AND LITERATURE OF SURGERY. 

Fabricius d'Aquapendente, became city physician at Ulm. His great 
work, the Armamentarium Chirurgicum (Ulm, 1653, folio), passed 
through many editions and was translated into many languages. 

Joseph Schmidt (1601-?), an army surgeon, published Speculum, 
Chirurgicum (Ulm, 1656, quarto) and Examen Chirurgicum (Francof., 
1660, 16°). 

The most celebrated German surgeon of the latter part of this period 
was Matthffius Gottfried Purmann (1649-1711 ?), who was apprenticed 
as a barber surgeon, became a medical officer in the Brandenburg army 
in 1675, and city physician at Breslau in 1685. He was a voluminous 
writer, and his Grosser und gantz neu-gewundener Lorbeer-Krantz, oder 
Wund-Artzney (Francof., 1692, 4to ; also 1722), his Chirurgia Curiosa 
(Francof., 1694, 4to; translated into English, London, 1706 .ol.), and 
his Funfftzig sender- und wunderbahre Bchusswunden Ch)' jii (Francof., 
1721) are valuable works in the history of the art. ^^e was a strong 
advocate of the cure by the weapon-salve and the sympathetic powder, 
and tells several stories of the successful use of these remedies, fie used 
styptics and bandages to control hemorrhages after amputations, objecting 
to the cautery, but says nothing about the ligature. 

Here may also be mentioned John von Muralt (1645-1733), a dis- 
tinguished Swiss anatomist and surgeon, who was one of a celebrated 
family of physicians of Zurich. He studied at Basle, Leyden, Oxford, 
and Paris, and in 1761 returned to Zurich, where he soon became dis- 
tinguished as an anatomist and surgeon. In 1677 he announced public 
lessons in anatomy, with demonstrations on the bodies of criminals and 
of persons dying of remarkable diseases in the hospitals, and in the 
same year published his Vade Mecum Anatomicum, giving the date by 
the enlarged letters in the motto of the book, " LVX et faX MeDICi- 
nse." In the second edition of his surgical writings, published in 1711, 
he describes a method of amputation by flap devised by Saborian in 
Geneva, who first performed it in 1701, and this is by some claimed to 
be the first mention of that method of operation, but it had alreadj' been 
described by Yonge in 1679. (See p. 67.) 

Other German surgeons of this period were Mathias Ludwig Glandorp 
(1595-1636), whose Speculum Chirurgicum appeared in 1619 ; Jessenius 
a Jessen (1566-1621), author of Institutiones Chirurgicae (1601); Paul 
Ammann (1634-91), author of Praxis vulnerum lethalium (Francof., 
1690); Joh. Agricola (1589-164?), author of Chirurgia parva (Niirn- 
berg, 1643) ; and John H. Jungken (1648-1726), author of Compendium 
Chirurgicae Manualis absolutum (Francof., 1692). 

The oldest English medical book which we have is perhaps the Leech- 
book, written about 970 a. d., and printed in 1865 as volume ii. of the 
Leechdoms, Wortcunning, and Starcraft of Early England. This is mainlv 
the receipt-book of a herbalist, giving the uses of common herbs, and 
among other things the composition of various " wound-salves." But it 
also contains matters taken from Paul of ^gina, and directs : " If thou 
must carve oif or cut off an unhealthy limb off from a healthy bodv, then 
carve thou not it on the limit of the healthy body, but much more cut or 
carve in the hole and quick body." The following is the best surgery in 
the book : " For hare-lip, pound mastic very small, add the white of an 
egg, and mingle as thou dost vermillion ; cut with a knife the false 



THE HISTORY AND LITERATURE OF SURGERY. 61 

edges of the lip, sew fast with silk, then smear without and within with 
the salve, ere the silk rot. If it draw together, arrange it with the hand ; 
anoint again soon." 

In the book of The Physicians of Myddoai, which dates from about 
the thirteenth century, there are a few references to surgical opera- 
tions. The author says (page 40) : " A wounded lung is the physician's 
third difficulty, for he cannot control it ; but he must wait for the will 
of God. By means of herbs a medicine may be prejmred for any one 
who has a pulmonary abscess [empyema]. He should let out [the 
matter] and support [the patient] aS in the case of a wounded lung, till 
he is recovered. But most usually he will have died within eleven years 
[or one year]." Page 44 : " A hard vesical calculus is thus extracted by 
operation : Take a staff and place it in the bend of the knee ; then fix 
both arms within the knees, doubling them over the staff, and securing 
both wrists with a fillet over the nape of the neck, the patient (being 
placed on the back), his stomach up, M-ith some support under both 
thighs, and the calculus cut for on the left side of the urethra. Let him 
subsequently be put in a water-bath that same day, also the day follow- 
ing early, and after this he should be put in the kyffeith. Then he 
should be removed to his bed, and laid there on his back, his wound 
being cleaned and dressed with flax and salt butter. He should be kept 
in the same temperature until it be known whether he shall escape [effects 
of the operation]. He should be kept without food or drink for a day 
and a night previous to the operation, and should have a bath." 

The following is the direction for an anaesthetic (page 423) : " Take 
the juice of orpine, eringo, poppy, mandrake, ground-ivy, hemlock, and 
lettuce, of each equal parts. Let clean earth be mixed with them and a 
potion prepared, then without doubt the patient will sleep. When you 
are prepared to operate upon the patient, direct that he shall avoid sleep 
as long as he can, and then let some of the potion be poured into his 
nostrils, and he will sleep without fail. 

" When you wish to awake him, let a sponge be pounded in vinegar 
and put in his nostrils. 

" If you wish that he should not wake for four days, get a penny- 
weight of the wax from a dog's ear, and the same quantity of pitch ; 
administer it to the patient and he will sleep. 

" When you would that he should awake, take an onion, compounded 
with vinegar, and pour some into his mouth, and he will awake. Take 
care that you keep him quiet, and warned of the operation, lest he should 
be disturbed." 

The first surgeon in England of whom we have any definite account, 
and whose writings still exist, was John of Arderne (or Arden), born 
about 1308, who practised in Newark until about 1370, when he went 
to London. He wrote a treatise on surgery of which several manu- 
script copies are in existence, but the only work of his which has been 
printed is A treatise of the fistula in the fundament, or other places of the 
body, eto., which is included with the translation of Arcseus on wounds 
of the head, etc., printed in London in 1688, being a translation by John 
Read. His operation itself consisted either of slitting up the fistula or 
of passing a thread through it, which is to be drawn so as to cut through 
the flesh gradually. 



62 THE HISTORY AND LITERATURE OF SURGERY. 

His description of cancer of the rectum is a graphic one, and begins 
as follows : 

" Bubo is an Apostume breding within the fundament in the longa- 
tion with great hardness, but with little paine. This before his ulcera- 
tion is nothing but a hid Cancer, which cannot in the beginning be 
knowne by sight of the eye, for it is hid within the fundament, and 
therefore it is called Bubo. For as an Owle hideth her self in the darke 
places, so this griefe lurketh within in the beginning. 

" But after processe of time it is ulcerat and frettith and goeth out, 
and oftentimes it frettith and iilcerith all the circumference of the funda- 
ment, so that the excrements goeth out continuallie without retencion, 
and may never be staied unto the death, nor cured by the healpe of man. 
And it is thus knowen. 

" Put your finger within the fundament of the pacient, and if ye 
finde within a thinge very harde, sometime on the one side, and sometime 
on both, Avhich hindreth egestion, than it is Bubo. 

"And the manifest signs are these. The patient cannot abstaine from 
stoole, for aking and priking, and that twise or thrise within an houre, 
and the excrementes seeme as it were mingled with watrie blond, and it 
stinketh very strongly, so that all the unskilfull surgions and the patient 
also thinketh they have Dissenterium, when truely it is nothing so, for 
Dissenterium is with flux of the belly, but in Bubo there goeth foorth 
hard egestion and sometime they may not goe out for straightnesse of 
the Bubo, but are reteyned within the fundament straightly so that ye 
may feele them M'ith your finger and drawe them out, and in this case 
glisters availeth much. 

" And when they bee nigh their ende, they beginne to have lynger- 
ing fevers, and to loose their appetite, they forsake all, and covet wine, 
they eate little and covet everieday lesse and lesse, they sleepe but little 
and unquietly, they are heavie as well in minde as in body, and as they 
waxe weaker and weaker, they covet their bedde and above all thinges to 
drinke water, neverthelesse they can speake and move themselves to the 
last breath. 

" From these (I say) wash your handes if you have care of your credit, 
unlesse it be in glisters as aforesaide to ease him." 

At the beginning of the fifteenth century there was a great dearth of 
surgeons in England, as it appears from Rymer's Fcedera that in 1417 
Henry authorized "John Morstede to press as many surgeons as he 
thought necessary for the French expedition, together with persons to 
make their instruments.' With the army which won the day at Agin- 
court there had landed only one surgeon, the same John Morstede, who 
indeed did engage to find fifteen more for the army, three of whom were 
to act as archers." 

Of the English surgeons of the fifteenth and sixteenth centuries, those 
whose names are best known are Vicary, Gale, Clowes, and Lowe. 
Thomas Vicary (149?-1561), the first master of the Amalgamated Bar- 
bers and Surgeons in 1641, and one of the first governors of St. Bar- 
tholomew's, published in 1548 a work on anatomy in English. No copy 
of this edition is known to exist, but the edition of 1577 was reprinted 
by the Early English Text Society in 1888. Thomas Gale (1507-86), a 
1 Tlie Antiquary's Portfolio, by J. S. Forsyth, vol. i., London, 1835, p. 80. 



THE HISTORY AND LITERATURE OF SURGERY. 63 

native of London, served in the army of Henry VIII. in France in 1 544, 
and under Philip II. of Spain in 1577, succeeded Vicary as master of 
the Barber Surgeons Company in 1561, and in 1563 published his Insti- 
tution of Chirurgerie, with other treatises, one of which is Of wouikIh 
made trith Gonneshot, in which he opposes the views of Brunswick, De 
Vigo, and Ferrius as to the venomous nature of such wounds, and quotes 
jNIaggius approvingly. He advises styptics in amputations — says that 
his method is used in St. Thomas's Hospital, and gives cases to prove 
that bullets may be left in the body without danger. 

William Clowes (1540-1624) was at first a naval surgeon, and became 
surgeon of St. Bartholomew's in 1581. He wrote A proved practise for 
all young Chirurgions concerning burnings with Gimpov^der and Woundes 
made with Gunshot, de. (London, 1591, 8° ; 3d ed. 1637, 4°). He refers 
to Par6 as a man worthy of admiration, and, like Gale, comments severely 
on the ignorance of the so-called surgeons of his time. Peter Lowe 
(155"?-161?), a Scotch surgeon, practised for a long time in France and 
Flanders and as an army surgeon. In 1596 he M^as in London, where 
he published his works on the Spanish Sickness and The ^Vhole Couri^c 
of Chirurgerie. In 1598 he returned to Glasgow, and founded the Fac- 
ulty of Physicians and Surgeons of Glasgow, which was chartered by 
King James VI. in 1599. His book on surgery passed through four 
editions, and is a good manual for its time. In amputation for gangrene 
he used the actual cautery, but says : " In amputation without putrefac- 
tion I finde the ligature reasonable sure providing it be quickly done." 
This is perhaps the first mention in English of the ligation of arteries in 
amputation. In hernia he advised the pricking of the intestines Mith a 
needle to discharge the wind and lessen the bulk of the tumor. 

About the middle of the sixteenth century there lived at Maidstone, 
Kent, a surgeon named John Halle, who published in 1565 a translation 
of the Chirurgia parva of Lanfranc, with some remarks of his own, entitled 
An Historical Expostidation also against the beastly abusers, both of Chy- 
rurgerie and Physiche in our tyme : With a goodly doctrine, and instruc- 
tions necessary to be marked and followed of all true Chirurgies. 

The history of surgical corporations in England begins with the bar- 
bers' guild, which was at first a meeting for social and religious purposes, 
originating probably in the thirteenth century. These barbers soon 
began to call themselves barber surgeons. There were, however, sur- 
geons \\'ho were not barbers, some of whom had served in the army, and 
in 1368 these surgeons formed a separate guild, which about 1421 com- 
bined with the physicians.^ The barbers obtained a charter of incorpora- 
tion from King Edward IV. in 1462. 

There is nothing in the charter about barbery — that is, shaving and 
hair-cutting — but a good deal about the regulation of surgery. In 1492 
arms were granted to the " Guild of Surgeons," which appears to have 
been a small body of eight or ten men superior in social position to the 

' The details of the quarrels between the barbers and the surgeons, and of the organ- 
ization and progress of the guilds, will be found in The Annals of the Barbel- Surgeons of 
London, compiled by Sidney Young (a thick quarto volume published in 1890), and in 
The Craft of Surgery, by J. Flint South (published in 1886). The act of Parliament 
passed in 1540, allowing the United Companies of Barbers and Surgeons to have yearly 
four bodies of criminals, was the first law in the country for promoting the study of 
anatomy. 



64 THE HISTORY AND LITERATURE OF SURGERY. 

barbers. In 1540, under the reign of Henry VIII., the barbers and 
the surgeons were united and incorporated by act of Parliament as the 
Company of the Barber Surgeons, the first master being Thomas Vicary. 

In the year 1542 an act was passed regulating the practice of surgery, 
stating that "the Company and Fellowship of Surgeons of London, 
minding their owne lucres, and nothing the profit or ease of the diseased 
or patient, have sued, troubled, and vexed divers honest persons, as well 
men as women, whom God hath endueed with the knowledge of the 
nature, kind and operation of certain herbs, roots and waters, and the 
using and ministering of them, to such as have been pained with custum- 
able diseases, as women's breasts being sore, a pin and the web in the eye, 
uncomes of the hands, scaldings, burnings, sore mouths, the stone, stran- 

guary, saucelin, and morphew, and such other like diseases And 

yet the said persons have not taken anything for their pains or cunning. 
.... In consideration whereof, and for the ease, comfort, succour, help, 
relief, and health of the King's poor subjects, inhabitants of this his 
realm, now pained or diseased, Be it ordained, etc. that at all time from 
henceforth it shall be lawful to every person being the King's subject, 
having knowledge and experience of the nature of herbs, roots^ and 
waters, etc., to use and minister according to their cunning, experience 
and knowledge, .... the aforesaid statute .... or any other Act 
notwithstanding." 

The Barber Surgeons had public demonstrations of anatomy and dis- 
sections in their hall, but it was forbidden that any of them should make 
dissections or give lectures on anatomy at any place other than said hall. 
The reader in anatomy was for many years a physician. 

In 1604 the company was presented with five hundred copies of the 
Tables of Surgery of Horatius Morus, a Florentine physician, translated 
by Richard Caldwell' (London, 1585, 32 pp. 8°). These books were 
given by Mr. Caldwell to be distributed among the surgeons who were 
freemen of the company. 

In 1643, Edward Arris gave to the corporation the sum of two hun- 
dred and fifty pounds for the purpose of having one human body pub- 
licly dissected and six lectures thereupon read each year. 

The Gale Lectureship was founded by Dr. Gale, the order being issued 
in 1698. These two bequests are now combined and the lectures in con- 
nection with them are known as the Arris and Gale Lectures. 

One of the lecturers before the Barber Surgeons was Alexander Read 
(or Rhead), a Scotchman, who graduated in 1 620 at Oxford. His Lec- 
tures on wounds were published in 1634, those on Surgical operations in 
1637, and all his works in 1650. Read taught that a bullet may be so 
made that it will make a poisonous wound, quoting as authority Querce- 
tanus. Speaking of ligature of the artery, he says : " Ambrose Parrey 
would have this mean to be used after the amputation of a member, whom 
you may read ; but in my judgment his practice is but a troublesome and 
dangerous toy ; as he shall finde who shall go to make trial of it." 

An important part of the business of the Corporation of Surgeons was 

' The Dr. Caldwell referred to was Eicliard Caldwell, a graduate of Oxford and a, 
physician, and president of the college in 1570. Through his influence Lord Lumley 
founded and endowed a lectureship on surgery, which is still known as the Lumleian 



THE HISTORY AND LITERATURE OF SURGERY. 65 

the examining and licensing of naval surgeons, both for the royal navy 
and for merchant ships. An account of such an examination is given by 
Smollett in his novel Roderick Random. Oliver Goldsmith also pre- 
sented himself for examination in 1758, and the minutes of the court of 
examiners read as follows : " James Bernard, mate to an hospital ; Oliver 
Goldsmith, found not qualified for dito." 

In Scotland the University of Aberdeen was founded in 1494, and in 
1505 had a professor of medicine. 

King James III. is reported to have been "ane singular gude 
chirurgian, and there was none of that profession if he had any danger- 
ous cure in hand but would have craved his adwyse." His method of 
obtaining priactice must have been effectual, although it was an unusual 
one. "We find in the accounts of the treasurer for 1511 an entry as fol- 
lows : " Item to one fallow, because the King pullit forth his tootht, 
xiiii. 5." 

The first charter of the Royal College of Surgeons of Edinburgh is 
dated July 1, 1505. It directs that no person shall make use of the 
craft of surgery or of barber craft within this burgh unless he is freeman 
and burgess of the same, and that he must be examined by the masters 
of the same craft upon the following points — namely : The anatomy, 
nature, and complexion of every member in man's body, and all the 
veins of the same. Every year one executed criminal was to be given 
to the college for anatomical purposes. No master of the craft shall 
take any apprentice who cannot write and read. Probably the most 
important provision was, that no person within the burgh shall make 
or sell any aqua vite except the masters, members, and freemen of the 
corporation. 

By 1589 it had become the custom to admit barbers at a lower rate, 
but they had only the right to act as barbers, being specially forbidden 
to practise surgery, and were to have " na signe of chirurgie in their 
bughts or houses oppenlie or privatlie." 

In the early part of the seventeenth century the leading British sur- 
geons were Clowes and Lowe, already referred to, and John Woodall 
(156?-164?), who had served as an army surgeon, and about 1612 was 
elected surgeon to St. Bartholomew's Hospital and likewise surgeon-gen- 
eral to the East India Company, which last gave him the appointing of 
surgeons and mates to all the company's ships. In 1617 he published a 
work entitled The Surgeons Mate or Military & Domestique Surgery. 
Discoursing faithfully & plainly the method and order of the Surgeons 
chest, the uses of the instruments, the vertues and Operations of the 
Medicines, and the exact Cures of Wounds made by Gun-shott, etc. 
In 1628 he published a work entitled Viatioum, Being the Path-Way to 
The Surgeons Chest. Containing, Chirurgical Instructions for the 
yonger sort of Surgeons, imployed in the Service of his Majestie, or 
for the Common- Wealth upon any occasion whatsoever. Intended 
chiefly for the better curing of Wounds made by Gunshot.' His 

' These works were afterward published together in folio in 1639, 1653, and 1658, a 
separate title-page being given to each work, but the pagination being continuous. The 
second title-page is often transferred in place of the first one, which has been lost, lead- 
ing, on careless examination, to the erroneous supposition that they are two entirely dis- 
tinct works of the same date. 
Vol. I.— 5 



66 THE HISTORY AND LITERATURE OF SURGERY. 

works are not specially instructive, but are in parts very good reading. 
In amputation he recomnaends tying large vessels, especially those of 
the thigh, if it can be done, but he seems to think that the surgeon 
will often fail, in which case, as well as for the smaller vessels, he 
recommends buttons of astringent and caustic powders. 

In gangrene Woodall urged amputation in the mortified instead of 
the sound part — an old treatment which had then fallen into disuse. 
He also suggests amputating as low as the ankle for disease of the foot, 
instead of just below the knee, as was usually the case. He had never 
seen the actual cautery used in amputation. 

In 1648, James Cook of Warwick published his 3IeUificmm Chirur- 
giae, or the Marrow of Surgery, a manual which seems to have been 
popular, the sixth edition in 1717 being "licensed by the College of 
Physicians and fitted for the use of all sea-surgeons." In his descrip- 
tion of amputation no mention is made of the ligature of arteries. 

The greatest English surgeon of the seventeenth century Mas Richard 
Wiseman (1622-76), sometimes called the English Par6. He M'as 
apprenticed to a barber surgeon in 1637, served in the Dutch navy until 
about 1644, when he joined the army under Chai'les I., and was admitted 
to the Company of Barber Surgeons in 1651. He was a surgeon in the 
Spanish navy for three or four years, and in 1660 joined King Charles 
II. and was appointed one of his surgeons. In 1672 he published A 
Treatise of Wounds in an octavo of 277 pages. In 1676 this was 
enlarged and printed in a large folio volume under the title Severall 
Chirurgieall Treatises. There were eight of these treatises — viz. I. Of 
tumors ; II. Of ulcers ; III. Of the diseases of the anus ; IV. Of the 
King's evil ; V. Of wounds ; VI. Of gunshot Avounds ; VII. Of frac- 
tures and luxations; VIII. Of lues venerea. In 1686 this was pub- 
lished in folio, having the words " the second edition " on the title-page, 
although it was really the third, and the so-called " third edition " (folio, 
1796), with the title Eight Chirurgical Treatises, etc., was really the 
fourth. Other editions appeared in 1705, 1719, and 1734, and there is 
a spurious edition of 1692, which is really the original edition of 1676 
with a new title-page. 

Wiseman used the complex dressings of the period, but knew that 
simple measures produced equally good results. He used styptics and 
cauteries, and not the ligature, but he included the end of the cut vessel 
in one of the stitches through the lips of the wound. Being a personal 
friend of the king, he used his influence with him to promote the inter- 
ests of the Barber Surgeon's Company. His works were never trans- 
lated, and were very little known on the Continent, but they had a 
decided influence on the improvement of the art in England. 

James Yonge (or Young) (1646-1721), a native of Plymouth and a 
naval surgeon, published in 1679 a little book of 120 pages entitled 
Currus Triumphalis, e Terebinths. Or an account of the many admirable 
Veiiues of Oleum Terebinthinae. More particularly, of the good effects 
produced by its application to recent Wounds." .... And, lastly A 
new Way of Amputation, etc. He objected to Park's method of liga- 
tures in amputations, saying that it is " a way always tedious often 
successless ; and whatever vaunts the Author makes of it, it cannot be 
so secure as he pretends ; it being liable (sometimes from the slackness 



THE HISTORY AND LITERATXTBE OF SUBGEBY. 67 

otherwise from the too great straightness of the thred ; sometimes from 
its smallness, cutting through, or from its weakness, giving way) to a 
new flux when not so tolerable to the Patient, or so easily cured by the 
Artist as at first ; moreover, where two Vessels or more bleed in one 
Wound (which is very frequent), the one must be neglected, while the 
Ligature is making on the other." But he says : " The ligation of an 
Artery on other accounts, as in the Toothach, Epiphora, Aneurisma, &c., 
is not hereby impugned." On page 30 is to be found, perhaps, the first 
printed description of a tourniquet — " very useful in Amputations, espe- 
cially above the knee ; that is to say a wadd of hard linnen cloth, or the 
like, inside the Thigh a little below the Inguen, then passing a Towel 
round the member ; knit the ends of it together, and ^vith a Battoon, a 
Bedstafi", or the like ; twist it, till it compress the Wadd or Boulster so 
very strait in the crural vessels that (the circulation being stopped in 
them) their bleeding when divided by the Excision, shall be scarce large 
enough to let him see where to apply his Eestrictives." A similar tour- 
niquet had, however, been used by John Morell in 1674 at the siege 
of Besanpon. The " new way of amputation " is by a single flap, and 
is the first printed description of this method, which he says he learned 
from Mr. C. D. Lowdham of Exeter. 

The Compleat Discourse of Wounds, . ... as also a Treatise on 
Gunshot Wounds in General, by John Brown (surgeon to the king) 
(London, 1678, 4to), is a pompous, diffuse, tedious book, containing 
nothing of any importance. 

Some curious illustrations of the English surgery of the middle of 
the seventeenth century are to be found in the Diary of the Rev. John 
Ward, Vicar of Stratford-upon-Avon, extending from 164-8 to 1679, 
edited by Charles Severn (London, 1839, 8vo). For example: "A 
cancer in Mrs. Townsend's breast, of Alverston, taken off by two sur- 
geons First they cutt the skin cross and laid itt back, then they 

workt their hands in ytt, one above and the other below, and so till 

their hands mett, and so brought itt out There came out a gush 

of a great quantitie of waterish substance, as much as would fill a flag- 
gon. They put in a glass of wine and some lint, and so let itt alone 
till the next day ; then they opened itt again, and injected myrrhe, aloes, 
and such things, as resisted putrefaction, and so bound itt up againe. .... 
The way how and where itt should be cutt was markt with ink by one 
Dr. Edwards." 

" Gill told mee of a woman that had an apostheme about the side, 
and his master intended to trepan her on one of the ribs ; whether it 
canne be ; — I suspected itt to be a ly." 

" The mountebank that cutt wry necks, cutt three tendons in one 
child's neck, and hee did itt thus ; first by making a small orifice with 
his launcet, and lifting upp the tendon, for fear of the jugular veins, 
then by putting in his incision knife, and cutting them upwards ; they 
give a great snapp when cutt. The orifice of his wounds are small, 
and scarce any blood follows." 

" Gill said his Mr. Day hath amputated five armes, three leggs and 
somewhat else since he came to Oxford, and but two of all these died, 
and one was a person of sixty years att least." 

" John Phillips his child had a red swelling in the forehead, I sup- 



68 THE HISTORY AND LITERATURE OF SURGERY. 

pose a varix or naevuss and itt was taken off by one of Coventry, by 
tying a hair about itt, and girding itt harder every day ; in two weeks 
itt fetcht itt off." 

A curious episode in the history of surgery in the first half of the 
seventeenth century is the controversy on the sympathetic or magnetic 
cure of wounds. This was a doctrine of Paracelsus, and in 1608 one 
of his followers, Goclenius, professor of medicine at Marburg, called 
special attention to it by his work, Traetatus de Magnetica Curatione 
Vulneris. His doctrines were objected to by the priests on religious 
grounds. Van Helmont wrote in defence of the doctrine, and his pam- 
phlet was published without his knowledge in 1621. This created great 
excitement, and was translated into English by Walter Charleton, and 
published in 1560 under the title A ternary of Paradoxes. The cure 
was to anoint the bloody sword or other weapon which had inflicted the 
injury, or a stone or cloth dipped in the blood as it flowed from the 
wound, with a special ointment, and put it away carefully, applying 
nothing to the wound but a bit of wet lint. Goclenius thought the 
cure was a natural process ; the priests thought it was due to magical 
formula and the aid of the devil ; and Van Helmont undertook to 
prov3 that both were wrong, and that the so-called " weapon cure " was 
due to a certain mysterious sympathy precisely analogous to what, in 
later times, was called "animal magnetism." 

The priests' view that weapon-salve cures are magical and sinful is 
given in the Hoplocrismaspongus ; or a sponge to wipe away the weapon- 
salve, by William Foster, Parson, etc. (London, 1631), which was directed 
mainly against the celebrated Rosicrucian Robert Fludd, who replied with 
Doctor Fludds answer unto M. Foster, or the squesing of Parson Foster's 
sponge, .... wherein the sponge-bearer's immodest carriage and be- 
haviour towards his brethren is detected, etc. (London, 1631). Fludd's 
book is much better reading than that of Foster. 

Sir Kenelm Digby's discourse at Montpellier, on the cure of wounds 
by the powder of sympathy, published in 1657, was a famous book in 
its day. A less-known but equally curious book, by C. de Irvine, an 
army surgeon, was printed at Edinburgh in 1656 under the title of 
Medioina Magnetica, or the rare and wonderful art of curing by sym- 
pathy, and several other controversial pamphlets of the period are 
noted in the Index Catalogue of the Washington Library under the 
heading "Sympathy." 

After the expulsion of the Moors from Spain there is little worth 
noting in the history of surgery in that country until after the middle 
of the sixteenth century. In 1488 it was ordered that those wishing to 
practise surgery must be examined under the direction of the Brother- 
hood of St. Cosme and St. Damian at Zaragoza, to which association 
was granted the privilege of dissecting the bodies of persons dying in 
the hospital recently established in that city. The surgeons were for- 
bidden to order or to dispense internal remedies. At the end of the 
fifteenth century there were a few Spanish writers on syphilis, the best 
known being Villalobos. 

The first celebrated Spanish surgeon was Francis Arcseus (1493- 
157?), whose treatise, De recta curandorum vulnerum ratione written 
in his old age, was first published at Antwerp in 1574 and again at 



THE HISTORY AND LITERATURE OF SURGERY 69 

Amsterdam in 1658. This was translated into English by John Read, 
and published at London in 1588, and a Dutch translation was published 
in 1667. Arcseus recommends the use of the trephine in fractures of 
the skull, describes with some minuteness the ojieration for excision of 
cancer of the breast and an apparatus for the treatment of club-foot, 
and advises mercurial inunctions on the joints for syphilis. Plis treat- 
ment of wounds is, in the main, that of John de Vigo. 

Another Spanish surgeon of the sixteenth century of some repute 
was Bartoleme de Aguero (1531-97), professor of surgery at Seville, 
called by some the Spanish Pare, whose works were published in 1 604 
under the title Tesoro de la verdadera cirujia, and in other editions in 
1624 and 1654. 

Dionisio Daya Chacon (1510-159?), a surgeon in the Spanish army, 
serving in many countries and in the immediate service of Charles V., 
Philip II., Juan of Portugal, Don Carlos, and Don John of Austria, 
wrote his Practica y feorica de cirujia about 1580. This was the first 
comprehensive work in surgery written in Spanish. He used the 
cautery for checking hemorrhage in amputations, did not consider gun- 
shot wounds poisonous, and abandoned the use of boiling oil in treating 
them after 1544, at the suggestion of a certain M. Bartolomeo, probably 
Maggius. His interesting report on the injury of the head of Don 
Carlos, in which he opposed Vesalius, who advised the trepan, is given 
with comments by J. M. Guardia in the Gazette MkJ. de Paris, 1863, 
p. 41. 

Andreas Alcazar, professor at Salamanca, published in 1575, in folio, 
his Chirwrgiae, .... libri sex, and in 1582 his De vulneribus capitis. 

Juan Fragosa, surgeon to Philip II., published Erotemas quirurgicos 
(Madrid, 1570, 4to), De la Cirugia, etc. (Madrid, 1581, fol.), Tratado 
de cirugia sacado de la cirugia universal, a little manual of questions 
and answers for students (1692), and Cirujia universal, . . . . Y mas 
otros tres tratados .... Una sum/ma de proposiciones contraciertos 
avisos de cirugia . . -. . de las declaraciones aoerca de diversas heridas 
y muertos . . . . de los Aphorismos de Hyppocrates tocantes a cirugia 
(Alcala, 1592, and several later editions). 

Cristobal Montemayor, surgeon of Kings Philip II. and III., wrote 
Iledicinia y cirugia de vulneribus capitis (Yalladolid, 1613; Saragossa, 
1664). 

Pedro Grago de Vadillo, a surgeon of Lima, published at Madrid, in 
1632, Discursos de verdadera cirugia y censura de ambar vices, y eleccion 
de la primera intendon curativa, y unicion de las heridas, of which a 
third edition appeared in 1692. 

Eighteenth OENTtrEY. 

At the beginning of the eighteenth century the only city in which 
there were any special opportunities for the study of surgery was Paris. 
There was no place for the barbers or the barber surgeons in the univer- 
sities of Europe, and they had no institutions of their own in which any 
teaching worthy of the name could be obtained. Many of them had 
learned something in the camp or on the battle-field, which was the 
great practice school for the surgeons, as it had been for three centuries, 



70 THE HISTORY AND LITERATURE OF SURGERY. 

and tliere were but few surgeons of the time in England, France, or 
Germany who failed to gain experience therein. Nevertheless, this 
military experience contributed little to the advancement of surgery. 
Haeser says that the chief cause of the supremacy of French surgery in 
the seventeenth and eighteenth centuries was the wars undertaken by 
Louis XIV. and his successors, and that streams of German blood con- 
tributed in some degree to the foundation of the mastership of the 
French in the domain of surgery. There is a grain of truth in this 
statement, but it does not explain why the German and the English 
surgeons, who also saw more than enough of military surgery at this 
period, did not make the same progress as the French. Army service 
gives valuable experience to the man who has suitable preliminary 
training and is well grounded in anatomy, but for the barbers and barber 
surgeons of the eighteenth century such service increased their knowledge 
but little. It is true that the surgeons had learned something. They 
knew that shot-wounds were not poisonous and did not require cauteriz- 
ing, and a large number of them probably also knew that ordinary wounds 
not involving the bones really required very little treatment. Never- 
theless, they kept on prescribing and using their oils, ointments, plasters, 
vulnerary drinks, etc., the formulae for which fill a considerable space in 
the surgical treatises of the day ; and there is one special reason for this 
which the modern surgeon and historian usually does not fully appreciate. 
This reason was, that the charges of the surgeons in those times were 
based upon these applications, and this was also true for the ordinary 
practitioners of medicine : they compounded and dispensed their own 
remedies ; their charges were made for the remedies and not for the 
visits ; and hence the fees were in proportion to the number of the 
mixtures, draughts, unguents, etc. which were ordered for a particular 
case. The surgeons at the beginning of the eighteenth century, as a 
rule, used styptic powders and compression to check hemorrhage. Those 
who knew anything about the use of the ligature appear to have been 
afraid to trust it, and to have preferred the actual cautery. It was sup- 
posed to be necessary, or at all events desirable, to include a portion of 
the surrounding tissues with the artery to be ligated, for fear that the 
ligature might cut through the coats, and for the same reason the cord 
was often tied over a small pad instead of being made directly to encircle 
the vessel. In the army the surgeons necessarily practised medicine, but 
in civil life they were, as a rule, forbidden to use or prescribe the internal 
remedies, that being the business of the physician, who claimed exclusive 
rights in this respect. 

Atthe beginning of the eighteenth century the leading surgeons in Paris 
were Georges Mareschal (1658-1736), surgeon of the Charit6 and first sur- 
geon of Louis XIV. in 1703 ; Jean M&y (1645-1722), first surgeon of 
the H6tel Dieu and the deviser of the operation of suprapubic puncture of 
the bladder ; and Pierre Dionis (165?-1718), who had commenced teach- 
ing anatomy at the Jardin du Roy in 1673, and in connection with his 
lessons gave demonstrations of surgical operations on the cadaver. He 
had many pupils, and his Corns d'opSratiovs de Chinirgie, first published 
at Paris in 1707, went through many editions and was translated into 
English, Dutch, and German, being a popular manual for fifty years. 
He advises the ligature of arteries in amputations, but says that at the 



THE HISTORY AND LITERATURE OF SURGERY. 71 

Hotel Dieu the vitriol button is used instead. He advises the Marian 
operation in lithotomy, but says that he does not believe the high opera- 
tion to be so dangerous as is supposed, and that he is assured that M. 
Bonnet has often practised this operation at the H6tel Dieu with happy 
success. He tells at length the story of Frfere Jacques up to that date, 
and apparently very fairly, showing the ignorance of the man, but saying 
that a surgeon who is a good anatomist may succeed by his method ; which 
was true prophecy. 

This Frfere Jacques — Jacques de Beaulieu (1651-1719) — was an 
ignorant peasant who for a time was a servant of an Italian Incisor 
named Palloni. He became a monk, or, as Dionis says, a sort of a 
monk, and came to Paris in 1697, as he said, to show the surgeons how 
to perform lithotomy in a particular way. He «as successful at first, 
and acquired great reputation, but soon had many deaths and left Paris, 
going in 1704 to Holland, where he taught his method to E,au, who 
improved it into what is generally known as the lateral operation. 
Frere Jacques himself improved his methods greatly after his visit to 
Paris, and spent the rest of his life as a wandering lithotomist, chiefly 
in Austria and Italy. 

There is much good reading in Dionis : he does not confine himself 
to a mere description of the operations, but gives anecdotes which furnish 
a picture of his times and surroundings. 

Gabriel le Clerc, a surgeon of Lille, published at Paris in 1692 a 
little book called La chirurgie compUte, being a sort of quiz-compend 
with questions and answers. This became a popular manual, passing 
through eighteen editions and translations. He mentions the Hotel-Dieu 
method of stopping bleeding arteries by vitriol buttons, and says that it 
is the custom of the Hotel Dieu to employ a person to keep on the 
dressing with the hand for twenty-four hours after the operation. 

B. Saviard (1656-1702), surgeon of the Hotel Dieu, published in 
1702 his Nouveau reoveil cV observations cliirurgicales, which was trans- 
lated into English and published at London in 1740. This is a valuable 
collection of cases, containing a description of the tourniquet (using that 
name) as applied at the Hotel Dieu in 1688 in a case of successful liga- 
tion of the femoral for a wound of that vessel. He refers to the per- 
nicious atmosphere of the Hotel Dieu and its effects on ^younds, gives an 
interesting note on Frere Jacques, describes a case of dermoid cyst of the 
ovary and one of congenital absence of the penis, and gives details of 
some remarkable cases of lithotomy. It is a book worth having. 

Rene Jacques Croissant de Garengeot (1688-1759) published his Traits 
des operations de chirurgie in 1720 (2d ed., 3 vols., in 1731). He was 
one of the best anatomists and surgeons of his time, and introduced 
many methods in details of operations for nasal polypus, hare-lip, stran- 
gulated hernia, etc. 

Alexis Littre (1658-1726), whose name remains connected with the 
form of hei'uia first described by him, was a surgeon who devoted him- 
self largely to pathological anatomy, and whose papers are contained in 
the Memoirs of the Academy of Surgery. He first proposed the opera- 
tion of colotomy in 1710. 

Xicolas Andry (1658-1742), dean of the medical faculty of Paris in 
1724, is known in the history of surgery by his L'Orthop)edie, ou I'art de 



a 



72 THE HISTORY AND LITERATURE OF SURGERY. 

privenir et de corriger dans les enfans Us difformites du corps (Paris, 1741), 
being the first work in which the word orthopsedia is used. It is a pop- 
ular treatise on the care of children, and has very little to do M'ith ortho- 
psedia as that word is now understood. 

The most distinguished surgeon of the first half of the eighteenth 
century was Jean Louis Petit (1674-1750), who entered the army at the 
age of eighteen. In 1700 he settled at Paris and commenced giving a 
private course of lectures in anatomy and surgery. He invented the 
screw tourniquet, an appliance of almost as much importance as the liga- 
ture to the surgeon who has to amputate with unskilled assistance, devised 
herniotomy without opening the sac, and made an improvement in the 
circular method of amputation by cutting successively the skin and the 
muscles, instead of dividing them at one stroke according to the old 
method. This was carried still further by Desault, who divided the 
muscles on two levels. To Petit also is due the credit of having first 
demonstrated the mechanism of the occlusion of arteries in wounds, 
showing the chief process to be the formation of a clot, a part of which 
surrounds the end of the vessel and a part of which is a plug occupying 
the cavity ; and of giving the first account of mollities ossium. 

After the triumph of the medical faculty over the surgeons and bar- 
ber surgeons in the middle of the seventeenth century, the College of St. 
Come continued to give instruction, although it could not grant degrees, 
and in 1690 the number of the students was greater than the number of 
students in medicine, being over seven hundred. It was by no means 
poor, and in 1691 it began the construction of a new amphitheatre, which 
was completed in 1694.' In it were given lessons on anatomy and sur- 
gical operations, and similar teaching was given by a few ambitious young 
surgeons as a private enterprise. To become a member of St. Come the 
aspirant must have been an apprentice for at least six years before he 
could present himself to perform his "grand chef d'ceuvre," M'hich, if 
successful, would make him a master surgeon. This "grand chef 
d'ceuvre " was a long process of examination. The Washington Library 
contains a manual of preparation for it, in the form of a neatly-written 
manuscript, bound in four volumes, 8vo, " par C. Caulay, r6cu chirurgien 
jure le 24 juillet, 1737." 

Franjois de Lapeyronie (1678-1747) was a surgeon of Montpellier 
and demonstrator of anatomy in the Scliool of Medicine. He came to 
Paris in 1714, soon became surgeon of the Charite, and first surgeon of 
the king in 1736. He was wealthy, and spent his money freely for the 
benefit of the Royal Academy of Surgery, which was organized in 1731, 
increasing in fame and prosperity for the next forty years, and through 
the agency of which, to a considerable extent, Paris became the great 
surgical centre of the world. J. L. Petit became the first director of 
the academy, and Sauveur-Franjois Morand (1697-1773) its first secre- 
tary. Morand was an ingenious surgeon. He proposed amputation at 
the hip-joint and ovariotomy, and performed the high operation for 
stone, but he was an uneducated man, and was unable satisfactorily to 
perform the duties of secretary of the academy, which post he resigned 
in 1739. He was succeeded by Antoine Louis (1723-92), to whom 
the success of the academy and its marked influence on the proo'rcss of 
1 Corlieu : La France Med., 1878, xxv. p. 481. 



THE HISTORY AND LITERATURE OF SURGERY. 73 

surgery are to a great extent due. He was professor of physiology, and 
in 1757 became surgeon of the Charity, but he was not so much an 
operator or inventor as he was a learned historian, editor, and critic. 

An indispensable work for the student of the history of surgery in 
France at this period is the collection of eulogies proiiounced by Louis 
upon deceased members of the academy, published with notes and 
appendices by E. F. Dubois in 1859. These so-called iloges are judi- 
cial, critical, historical essays which are unequalled in surgical biography. 
At the commencement of his eulogy on Le Cat he remarks that these 
memoirs will form a part of the history of the Academy to be read in 
years to come, and that the truth must be told ; and in this he was a 
true prophet. His OEuvres diverses de chirurgie were published in 1788. 

Of the earlier members of the academy, besides those already named, 
the most distinguished were Le Dran and Le Cat. Henry Franpois le 
Dran (1685-1773), the son of a surgeon, was educated in Paris, and 
became a master in surgery at the age of twenty-two. In 1724 he was 
appointed one of the four surgeons of the Charite, and established an 
anatomical school there, and in 1730 published his Parallele des dife- 
rentes mani&re de tirer la pierre hors de la vensie, which gave him much 
reputation. In 1734 he was sent as chief surgeon to the army, and pub- 
lished the result of his observations in 1737 in his Traite .... sur les 
'playes d'armes a feu, which went through several editions. In 1742 he 
published a treatise on operative surgery. Le Dran made no great con- 
tribution to surgery, but he was a celebrated teacher and had many 
pupils from Germany, through whom his method became popular in 
that country. 

Claude Nicolas le Cat (1700-68) was a surgeon of Rouen, who 
became surgeon-in-chief of the Hotel Dieu of that city as the result 
of concours in 1729. He won many prizes from the Academy of Sur- 
gery in Paris, being specially skilled in " prize-essay writing," became 
professor of anatomy and surgery in the school established at Rouen in 
1736, and attracted many students. He was a voluminous writer, but 
his papers which relate to lithotomy are the only ones of any special 
value. His reputation was greater abroad than it was at home. 

Other surgical writers of this period are Guillaume Mauquest de la 
Motte (1655-1737), whose TraiU oomplet de chirurgie (3 vols., Paris, 1722) 
was a very popular text-book ; Georges de la Faye (1699-1781), whose 
Prinoipes de chirurgie (Paris, 1739), an elementary handbook, passed 
through many editions and translations ; and Elie Col de Villars (1675- 
1747), whose Cours de chirurgie appeared in 1738. 

Dominique Anel (1678-1725 ?), a native of Toulouse, was a pupil of 
J. L. Petit, a surgeon in the French and Austrian armies, and a wan- 
derer over Europe. In 1710 he ligated the brachial artery of a priest 
in Rome for traumatic aneurism, and this is claimed as a triumph of 
French surgery preceding the method of John Hunter. In fact, it Avas 
the operation performed and described long before by Guillemeau. In 
Genoa, in 1712, he devised his operation for lachrymal fistula and the 
syringe which still bears his name. In 1716 he was practising as an 
eye surgeon in Paris. 

George Arnaud de Ronsil, a French surgeon, went to London prior 
to 1748, and remained there until his death in 1774. His Dissertation 



74 THE HISTORY AND LITERATURE OF SURGERY. 



on 



Hernia (London, 1748) was a paper of much importance. His 
M&moires de ohirurgie (London, 1762, 2 vols. 4to) contains matter of 
permanent value, and a curious paper, " Inconveniens des Descentes par- 
ticuliers aux Pr6tres de I'figlise Romaine," with reference to Leviticus 
xxi. 20. In 1732 he excised the caecum and a part of the colon and 
ileum in a case of hernia. 

Jean Baseilhac (1703-81), better known as Fr6re Come, was the son 
of a surgeon and was educated as such. In 1729 he became a monk, 
but continued to practise surgery among the poor, and invented the 
lithotome cache. He published anonymously in 1751 an account of 
his operation, and in 1779 published a paper on the high operation. 
He was a skilful surgeon, and obtained greater success with his instru- 
ment than any other person has been able to do. 

Pierre Brasdor (1721-97) was professor of anatomy and operative 
surgery in the College of Surgeons of Paris, and contributed to the 
Memoirs of the Academy of Surgery. His name is remembered in con- 
nection with his suggestion to treat certain aneurisms by ligation of the 
artery on the distal side of the tumor ; which was first done by Wardrop. 

Francis G. Levacher published in the Memoirs of the Academy of 
Surgery, in 1769, a paper on gunshot wounds, in which he, for the first 
time, showed that what were supposed to be the etfects of the wind of a 
ball were really due to the ball itself. 

Hugues Tiavaton, a surgeon of the French army, published in 1750 
the best treatise on gunshot wounds which had yet appeared. His 
Chirurgie d'armSe was issued in 1767, and his Pratique moderne de la 
chirurgie in 1770. He was the first to practise amputation by the 
double-flap method. 

Jean Joseph Sue (1710-92), son of a Paris surgeon, and often men- 
tioned as "Sue le jeune," was a teacher of anatomy, and in 1761 one of 
the surgeons of the Charit6. He published EUments de chirurgie (Paris, 
1755), Traite des bandages (Paris, 1761), and Dictionnaire positif de 
chirurgie (Paris, 1779). 

Jean Louis Belloq (1730-1807), a professor of anatomy in Paris, 
devised a number of instruments, among which was the canula for 
plugging the posterior nares still known by his name. 

In the latter part of the century the leading surgeon in Paris was 
Pierre Joseph Desault (1744-95), who became surgeon of the Hdtel 
Dieu in 1788, and soon had a crowd of students following his public 
clinic, the like of which had never been seen before. He was a pupil 
of Louis and of Morand, and surgeon of the CharitS in 1782. He 
was the first teacher of surgical anatomy in the modern sense of the 
term, made many improvements in the treatment of fractures, and con- 
tributed largely to the perfecting of surgical technique. He wrote 
almost nothing, but his pupil, Bichat, gave the substance of his teach- 
ings in the OEuvres chirurgicales (3 vols., 1798-1803). In 1792 Desault 
was arrested on the charge of having poisoned the wounds of some of the 
revolutionists who had been brought to the Hdtel Dieu. It was then but 
a step from the prison to the scaffold, and his pupils formed themselves 
into a deputation to defend him before the tribunal, their spokesman 
being Jean Pierre Maunoir, a young Swiss, afterward a celebrated sur- 
geon in Geneva, whose pleadings prevailed and Desault was relea,sed. 



THE HISTORY AND LITERATURE OF SURGERY. 75 

The H6tel Dieii of Paris was the " oldest, largest, richest, and worst 
hospital in Europe." In the latter part of the eighteenth century it con- 
tained over twelve hundred beds, and sometimes over three thousand 
patients, having four or five in one bed. The first distinct mention of 
surgeons in the Hdtel Dieu occurs in the records of the year 1539, in 
which it is ordered that the surgeon Jocot la ISTormand shall be retained 
to serve as surgeon in the H6tel Dieu in place of George Barbas at a 
salary of about one hundred and eighty francs. By declaration of the 
managers in 1605 the surgeon must call a physician to see all the opera- 
tions of surgery which he shall make within the Hotel Dieu. 

In 1654, Jacques Petit, master of surgery in Paris, was named sur- 
geon of the Hotel Dieu. This was an invasion, for up to that time the 
surgeons had been chosen from among the surgeons of the hospital. 
This Jacques Petit gave a course of anatomy to the pupils in the hos- 
pital, commenced the collection of instruments of surgery, and gave a 
sort of course of surgery at the bedside. This was the beginning of 
clinical surgery in this hospital and in France. He entered the hdtel 
at the age of thirteen, studied surgery there, and filled the place of sur- 
geon-in-chief until 1705. The story was that he was more than sixty 
years in the house without putting his foot outside of it. 

He was succeeded in 1705 by Mery, one of the most celebrated of 
the surgeons of this period. M6ry was succeeded in 1722 by Thibault, 
he by Pierre Boudou, and he by Moreau, who was succeeded by Desault 
in 1786. Desault was succeeded by Pelletan in 1795. 

The records of the Hdtel Dieu which escaped the fire of 1871 have 
been published by the Bureau of Public Assistance under the title Col- 
lection de documents pour servir a I'histoire des hopitaux de Paris (Paris, 
1881-87). In the second of these volumes, published in 1883, are given 
the deliberations of the governors of this hospital for the years 1768 to 
1791, at the time when the hospital was badly overcrowded and com- 
plaints were being made by the surgeons of the management of the 
institution. Among other things, it contains a copy of the memoir of 
the Sisters in charge of the hospital, who in 1789 made a complaint 
against Desault to the effect that he was bringing pupils from the out- 
side into the amphitheatre, which should be reserved for the pupils of 
the hospital alone, that the dressing of wounds was being interfered 
with, and that from two to three hundred strangers were admitted every 
day to hear his lectures. To this there is a long reply by Desault, show- 
ing that the complaints were in part ill founded, and urging that it is 
contrary to the public good to confine clinical instruction to the pupils 
resident in the house. The matter was investigated and the decision 
was given in favor of Desault. A very interesting description of the 
old Hdtel Dieu, showing the arrangement and character of the beds and 
furniture, overcrowding, etc., is given by Dr. J. B. Tenon (1724-1816) 
in his Memoiren sur les hSpitaux de Paris (1788, 4to). 

Franpois Chopart (1743-95) became professor in 1771, and in 1780 
published, with Desault, the Traite des maladies ehirurgicales et des 
operations, etc., which contains some of Desault's views, but which was 
wholly written by Chopart. His name remains connected with a form 
of partial amputation of the foot first described in 1792. 

Eaphael Bienvenu Sabatier (1732-1811) was a pupil of Petit, and 



76 THE HISTORY AND LITERATURE OF SURGERY. 

became professor of anatomy in the Royal College of Surgery. His 
principal work was his JDe la midedne operatoire{3 vols., 1798-1810). 

J. Fr. Deschamps (1740-1824), a pupil of Moreau and surgeon of 
the Charitg, brought the Hunterian operation for aneurism into notice 
in France, and published an interesting historical treatise on lithotomy 
in 1796. 

Frangois Quesnay (1694-1774), secretary of the Academy of Surgery, 
wrote a work on the history of surgery in France which is full of errors. 

Antoine Portal (1742-1832), professor of anatomy in the Royal Col- 
lege of France, is the author of Histoire de I' anatomic et de la ohirurgie, 
etc. (7 vols., Paris, 1770-73), which is a useful book of reference. 

Jean Ren6 Sigault studied surgery at Paris, and was received as mas- 
ter in the school in 1770. In 1768 he presented a memoir to the Royal 
Academy of Surgery proposing to substitute the section of the symphysis 
of the pubis for the Csesarian section. The proposal was not approved, 
but he performed the operation in 1777 with success, and, as he had 
become a doctor of the Faculty of Medicine, his new operation was 
received with great enthusiasm by the members of the faculty. He 
published his Memoire [sur la section de la symphyse des os pubis, 
pratiquie sur lafemme iSouchot^, lu nux assemblers du 3 etdu 6 deoembre, 
1777 (16 pp. 4to, Paris, 1777), and Discours sur les avantages de la 
section de la symphyse (8vo, Paris, 1778). 

Georg Fischer, in his Ohirurgie vor 100 Jahren (Leipzig, 1876), has 
given a graphic picture of the condition of surgery and surgeons in 
Germany in the eighteenth century. The great mass of the people 
could only obtain surgical treatment from local barbers or from wander- 
ing charlatans. The barber's apprentice could hardly write or even 
read German. He learned how to shave, and then went from house 
to house to serve his master's clients. He was also taught how to 
sharpen knives, spread blisters, and make lint. He performed the most 
menial duties in the house, and occasionally one of the unhappy youths 
ran away and was duly advertised as a sort of runaway slave. The 
people were grossly ignorant and intensely superstitious, believing in 
charms and magic ; and the supply of this kind of medicine was not 
wanting. The cutters for stone and hernia, the cataract-operators, the 
bone-setters, and the travelling charlatans flourished everywhere, and 
the repeated edicts and ordinances issued by kings, nobles, and city 
authorities to remove the complaints made by the physicians and to settle 
the difficulties merely prove the condition of the times and seem to have 
had very little effect. Even the executioners competed with the sur- 
geons. They were supposed to have special dealings with the powers 
of evil, and in consequence to have special knowledge of the means of 
curing diseases considered to be due to witchcraft. A part of their busi- 
ness was to dislocate joints by the rack or to break bones upon the wheel, 
and hence it was supposed that they had special skill in the repair of 
fractures or of dislocations. 

The practice of medicine was forbidden to the executioners in Prussia, 
but in the year 1744 Frederick the Great granted to them permission to 
treat fractures, wounds, and ulcers, and when the Berlin surgeons com- 
plained of this he issued an order saying that he had not permitted all" 
executioners, but only the skilful ones, to practise, and if the surgeons 



THE HISTORY AND LITERATURE OF SURGERY. 77 

are ua s-tilful as they pretend to be, every one will rather trust them than 
go to an executioner ; but if the surgeons are ignoramuses, the public 
must not suifer, but must submit to be treated by the executioner rather 
than to remain lame and crippled. 

In Germany the first surgeon of importance in the eighteenth century 
was Lorenz Heister (1683-1758), a native of Frankfort-on-the-Main. 
After studying medicine for four years at Giessen and other German 
universities, he went to Amsterdam in 1706 to study anatomy and sur- 
gery under Ruysch and Rau, and took his degree at Leyden in 1708. 
He gained experience in the army hospitals at Brabant and Flanders, 
made a tour into Great Britain, and in 1710 became professor of anatomy 
and surgery in the University of Altdorf. Here he lectured in Latin, but 
found the students and young surgeons so ignorant that he determined to 
print his system of surgery first in German, which he did at Nuremberg 
in ] 718, as he states in his preface to later editions, and as given in bibli- 
ographies. I have, however, never been able to see a copy of this date, 
the earliest edition in the Washington Library having the imprint "Niirn- 
berg, bey Johann Hoffmanns seel. Erben, im Jahr mdccxix." The work 
was a very popular one, and was translated into Latin, and thence into 
English under the title of A general system of surgery (1743; 7th ed. 
1759), forming a thick quarto which is still excellent reading for a 
surgeon. Sharp says, in the preface of his Critical enquiry (1750), 
"Heister's Surgery is in every body's hands, and the character of 
Heister is so well established in England, that any account of that 
work is needless." 

The other German university professors of surgery in the first half 
of the eighteenth century who are Avorthy of note are Haller, Platner, 
Mauchart, and Bass. 

Albrecht von Haller (1708-77), a native of Bern, a pupil of Boer- 
haave, and one of the greatest physicians who ever lived, was professor 
of anatomy and surgery in the University of Gottingen from 1736 to 
1753, and exerted a powerful influence on the development of anatomy, 
physiology, and surgery through his writings and his pupils, who came 
to him from all parts of Europe. He never performed a surgical opera- 
tion on the living body, and his teaching in surgery was therefore purely 
theoretical. His Bibliotheea chirurgka (2 vols., Berne, 1774-75) is the 
most valuable work on the history and literature of surgery that has ever 
been published. He placed on a firm foundation the experimental method 
in dealing with surgical problems which was a little later so successfully 
employed by John Hunter, and which has contributed so much to our 
knowledge during the present century. 

Johann Zacharias Platner (1694-1747) was professor of anatomy and 
surgery in the University of Leipzig from 1724 until his death. His 
Institutiones chirurgice rationales turn medicos, etc. (Leipzig, 1745) passed 
through several editions and was translated into German and Dutch. 

Burchard David Mauchart (1696-1751) studied at Tiibingen, Altdorf, 
and Paris, and became professor of anatomy and surgery in the Univer- 
sity of Tubingen in 1726. He devoted himself chiefly to the anatomy 
and diseases of the eye, and left no systematic treatise, but published a 
humber of dissertations, which were collected after his death and pub- 
lished in three volumes (Tubingen, 1783-86). 



78 THE HISTORY AND LITEBATVEE OF SUEGEEY. 

Heinrich Bass (1670-1754) becaine professor of surgery in the Uni- 
versity of Halle in 171S, and in 1720 published his GrUndlichcr Bericht 
von Bandagen, which was a favorite text-book for the next fifty years. 

The great difficulty experienced by the government in providnig 
competent suroeoiis for the troojis led to the orgiinization in 1724, at 
Berlin, of a niedico-chirurgiciil college, the Friedrich AVilhelms Institut. 
In 1727 the Charity Hospital was founded by King Friedrich Wilhelni I., 
mainly to furnish clinical instruction to the students of this college. The 
supply, however, was not equal to the demand, for Frederick II. iu his 
Silesian campaigns found an urgent need for skilled surgeons, and sent 
some of his yomig officers to Paris and Strnsburg to jierfect their educa- 
tion and to "fit themselves to instruct others, and in 1743 he engaged 
twelve French surgeons and assistants for the benefit of his troops. Tlie 
results were not altogether satisfiictory, because surgery was generally 
considered to be distinct from and inferior to medicine ; those who were 
destined to it were usually apprenticed to barbers, and the young sur- 
geons were, as a rule, men of an inferior class and of little education. 
Finally, in 179."), as the result of urgent appeals from Giircke, the sur- 
geon-general of the Prussian army, the college was reorg-anized under 
the name of the P^piuiere, and was devoted exclusively to the education 
of medical officers for the army, retaining a special connection with the 
Charity.' An institution similar to tlie Pt^piniere, and for the s;ime pur- 
pose, was organized in Dresden in 1748 as the "Collegium ]N[edico- 
cliirurgicnm." - 

The three German military surgeons of chief repute during this period 
were Sehmucker, Bilguer, and Theden. 

Johann Lebrecht Schmncker (1712-8(5) was educated at the P(?piniere, 
and sent to Paris for two years by the king to study under Le Dran. 
He became the surgeon-general of the army, and published the results 
of his experience in his Chtrurginchc Wahrnehiuuiigcn (2 ])arts, 1774) 
and Vcnni-svlih' ehirurgixehc !^ehriftc)i (3 vols., Berlin, 1770-82). His 
observations on wounds of the head and trephining and on amputations 
are the most valuable of his writings. 

Joh. Ulrich Bilguer (1 720-9(3) studied at Strasburg and Paris, and 
entered the army in 1741. In 1757 he became the second surgeon- 
general. In 17G1 he published his i^c iiumbrontiii anipiifafionc rarissimc 
atlministr(()i(Ja, etc., which passed through numerous editions. In this he 
opposed the excessive tendency to amputation of his time, which was 
rather encouraged by Schmncker, and went to the other extreme. His 
Chinirgischc Wahniehmungcii (Berlin, 1763; translated into English, 
London, 1764) is his most important work. 

Joh. Christ. Anton Theden (1714-97) was educated as a barber siu- 
geou, entered the army in 1737, and became third surgeon-general in 
1758 and first surgeon-general in 1786. His Xvkc BciiierhuKfcn iind 
Erfahrniigoi zur Bciriehcndig der Wioidarzuct/k-unKf und Mcdiclu (pub- 
lished in 1771 and later editions, also in a French translation) contains 
accounts of some remarkable cases and surgical methods — so remarkable 

^ For details consult Das Kiiniql. prcus. Moi.-chli: Frifdricli Wilhelms rn^liliil von !"> 
E. Preiiss, Berlin, 1S19, 8vo. 

'' For the history of this see Das Kliiiiqlich sacfoisc/ic Collt'iiitnii 3Ii:dico-chinirniciim von 
Dr. H. Frolich, im Der Feldiu-zt, ^Viell, 1877, No. 9. ' ' ' 



THE lIIsroltY AND IJTEIlATIinr: Oh' SIU!(IEI!.Y. 79 

ill liic.l., iiw |,o cxcilc, Home HiiM|)icJ(iii. For tin: li);'iil.iirc of iiHcrics In ;i,iri- 
|)iil;iliiin li(! Hiil)sliliil(!(l ^riHliiiili'd (rdinpi-cswcs iiiid llic use iil' u ccrhiiii 
woiidcrCiil lolioii, Ihc " iinnicl)Msii(lc," coinposcd oC vin('};:ir, idcoliol, siif^iii-, 
iiikI (Millie Hnlplmric iicid, willi Hoino siill- (if lend. IIi' slroiifrly advuciilcd 
inclliiidinil hiiiKiafi'lii^' of the cxlrciiiilics, (■Jiiililillf; hy ilw use (o iiiive 
ciircd ,'iiieiiriHiii, viifix, <il(\' 

III the hisl Jiiill' III' llii' (■(•tiliiry (lie (wo (diicf (Jcriiiini Hurj^coiis wci-c 
Von Sicliold iiikI K'iclilcr. 

Carl Oasiicr von Sicliold ( 1 7.'{(!-18()7), llir son and upjiivnl ice ol' a, 
siirj^con, Hci'vcd Cor ii. lime in Frciic.li liospiliilH, iuid sliidicd in I'ariH 
Milder Moraiid and in London under Toll- and IJroiiilield. Jn 17()i) \w, 
iieeaiiie pnil'essor of Miiatoiny, siirn'cry, and ohsleli'ies ai Wiirzhlirf;', and 
soon M,e(piir('d f;reai iH'piilation as lUi operalor and elinieal leaclier. II(! 

was Slice led as professor luid as siii'f^'con ol' llie. Julian Hospital !))■ Iiis 

son, -loll. I'>arlli. Siehold (1771-1811), who I'oiinded a journal called 
('liiriiii, dcvoled lo Hiirj^'cry. 

Ailfriisl. (Jolllicl) Iv'icliler (17I'J-I.S]'2) liceaiiie prol'essor of siirfi'cry in 
(iliillinf^en in I7()(i, and puc a new impulse lo llic study of tlial art in 
(icrmain', beiiifr the lirsl- lo place il. on a siricntilic biisis. He was the 
liest leaclier ol' snrfrery in ( Jei'miiny in his day, had travelled exleiisi\'ely, 
was Camiliar with the fi;ood work tJicn }i;oiii[;' on in l''nincc and Eiif^-liind, 
and was an execllcnt. writer. His /I/iIhiikI/iiii;/ iiini, <lcii, /tri'ic/irii. 
( 1777-7'.)) was tlui best hook on hernia, np to that date, and is still 
a, classic. His histury (if snr^'cry, A iifdiii/M/rHinli' drii, Wmiddrziicjikiiiixl 
(7 vols., 1 7M1! -IHO I), is a. model in arranj^'cmciit and style, hut is not 
e()m|ilcte. His jonrnal, the ( 'hinirj/lM'hi'. liihlidlhck {\^) vols., 1771-1)1!), 
did more to develiip siirj;('ry in (icriiiany llian any pre\'ioiis aj;'cncy. 

In Austria, there is little worthy of note in the history of surgery 
until the latter part of the eeiiliiry. (icrard van Swieten (1700-7li), a 
pupil and friend of HocrhaaA'c, went to Vienna in 17 15 and introduced 
elinieal insi ruction, hnt the only suri:;eon of repute llierc in 17S() was 
l''cr(liiiand x'oii Ijchcr, who is principally known liy the inveslioation 
which li<! made upon the use of lorliirc in jui'ispriidenee. In 1785 the 
Military IVIc(lie()-( 'liirni'f:;ica,l Akadcniii! was founded by the emperor 
.losc|ili I I. and plaeed under the direct, inn (if IJrainbilla, the object beinji; 
the same as that of Ihc Hcw'lin lV:pini("^re. It was eonneclcd with a hos- 
pital of IwcK'c luindreil beds, and rccei\-cd one hundred |)iipils, of whom 
Iwciily-foui" were I'cwidenls in i\w house. The course of stud)' was two 
years, and alter passinj;' the exaininalion the student rec,ei\'C(l thi^ den'ree 
of doclor in surgery and the lirst vacant posilion in a, re}j,iinent. 

(Jiovanni .Messandro Hrainbilla ( 17'J.S-18()()) was iiii Italian who had 
studied in l'a\'ia, and became a sur^'cdn in the Austrian army and a, special 
favorite of the emperor. He prepared the I iixIriiLiioii fiir die /'rrj/'cy- 
K(ir<'ii (Irr k. k. f/iinuylKc/ifii MHiluntkailviiiir (Wieii, 1781, ltd) and the 
liiHlndiioii fi'ir ilus /•. /,-. MiUliirKjiildl zii Wwii (Wien, 178 I, Ito), wliieli 
are curiosities in lilcralurc. The subjects and Ihc order of llm subjects 
to be lannht are selu^duled for each professor. He also published a 
lar^'c atlas of enf;'i'a,vini;'s of surf;•i(^'ll iiistriimcnls and a history of dis- 
coveries nia,(lo by Italian aiiatomisls and physicians, and exerted a povvei- 

' l''(ir (IcIiiilH iiH (() llic iiiililMi-v Hiii'jj;t'r.y el' IIii'hc IIiiichhco /'iV l\'i-icji«-('liinirijir <lcr 
If.lzili l.'ill Jiilitr in rifiiKscii, voii l>i'. 10, (llirll, Iksrliii, IS7.''i. 



80 THE HISTORY AND LITERATURE OF SURGERY. 

ful influence upon the progress of surgical education, although he made 
no special improvements himself. A prot4g6 of Brambilla was Joh. 
Nepomuk Hunczovsky (1752-98), a barber's apprentice, who in 1781 
was appointed professor in the military medical school at Gumpendorf, 
and published a compendium of surgical operations in 1785, of which 
there were three later editions. 

At the commencement of the eighteenth century Holland was a great 
centre of medical instruction : Boerhaave had introduced clinical teach- 
ing at Leyden, where Bidloo was also lecturing ; Ruysch and E,au were 
teaching in Amsterdam, and all who desired a complete education in 
surgery visited these schools. 

Frederik Euysch (1638-1731) commenced teaching anatomy in Ley- 
den in 1666, and became famous for the perfection of his anatomical 
preparations, and especially for his injected preparations. His collection 
was purchased by the czar, Peter the Great, but a part of it was lost 
before it reached St. Petersburg. His numerous essays relate chiefly to 
anatomy, but contain some surgical observations. 

Joh. Jac. Rau (1668-1719), a native of Baden and an apprentice of 
a barber surgeon in Strasburg, studied at Leyden and Paris and settled 
in Amsterdam, where he gave lessons in anatomy and surgery, to the 
great dissatisfaction of Ruysch. Having learned from Fr&re Jacques 
his method, he improved upon it and acquired great fame as a lithoto- 
mist, but kept secret the details of his method, which was probably the 
lateral operation. He wrote nothing of importance, but had many dis- 
tinguished pupils. 

To this period belong Abram Titsingh (1685- ?) of Amsterdam, city 
surgeon, surgeon of the admiralty, and master of the Surgeons' Guild, Avho 
wrote works on lithotomy, spina bifida, venereal diseases, etc. which 
were valuable in their day ; Joh. Daniel Schlichting (1703-?), a lecturer 
on anatomy and surgery in Amsterdam in the middle of the century, 
said to have been the first to perform neurotomy for neuralgia of the 
fifth pair; Jos. Monnikhof (1707-87), appointed herniotomist of Am- 
sterdam in 1752, who in 1775 published statistics of one thousand cases 
of hernia, the first collection of this kind which had appeared ; and 
Charles Faudacq (1691-175?) of Namur, who studied in Paris under 
Petit, and published Reflexions sur les playes, etc. (Namur, 1735), and 
Nouveau traiti des plaies d' armes-ct-feu (Namur, 1746). 

In Ghent the leading surgeon was Joh. Palfyn (1650-1730), educated 
in Paris, master of the Barber-Surgeons' Company in Ghent in 1698, and 
professor of anatomy and surgery in 1708. He is best known by his 
Anatomie Chirurgicale, first published at Paris in 1726, and the first 
treatise with the title of "Surgical Anatomy." 

In the last half of the century the most celebrated teacher in Hol- 
land was Peter Camper (1722-89), a native of Leyden, who became pro- 
fessor of anatomy and surgery in Amsterdam in 1755 and professor in 
Groningen in 1763. He was one of the most learned men of his time, 
and a voluminous writer on anatomy, pathology, and medical jurispru- 
dence. His treatise on calculus (1782), his dissertation on fracture of the 
patella and olecranon_(1789), and his Icones herniarum, published after 
his death by Soemmering, are valuable contributions to surgical literature. 

Among the Italian surgeons of the eighteenth century the best 



THE HISTORY AND LITERATURE OF SURGERY. 81 

known are Benevoli, the two Nannonis, Lancisi, Valsalva, Tacconi, 
and Bertrandi. 

Antonio Benevoli (1685-1756), a surgeon of Florence, discovered in 
1722 that cataract is an opacity of the lens, and published his Discord 
di chirurgia in 1750. He discovered the principle of treating stricture 
of the urethra by dilatation. 

Angelo Nannoni (1715-90) studied in Florence under Benevoli, and 
afterward in Paris and Rouen, and became chief surgeon of the hos- 
pital Santa Maria Nuova in Florence, attaining great reputation. His 
principal works are Trattaio ohirurgioo sopra la sempUcitd, del medicare 
i mali d'attenenza della chirurgia (1770) and Memorie sopra alcuni casi 
rari di chirurgia (1776). 

Lorenzo Nannoni (1749-1812), son of Angelo, studied under his 
father, and became surgeon to the Hospital of the Innocents in Flor- 
ence, where he gave clinical teaching. His principal work is Trattato 
delle materie chirurgiche, etc. (2d ed. 3 vols., 1793-94). 

Giovanni Maria Lancisi (1654-1720), professor of anatomy at Rome 
and physician to Popes Innocent XL and XII., is best known as an 
anatomist, but in his De motu cordis et aneurysmatibus, first published 
after his death in 1728, and in four later editions, he first clearly pointed 
out the difference between true and false aneurism. 

Antonio Maria Valsalva (1666-1723) studied at Bologna, graduating 
in 1687, and became professor of anatomy in the university and sur- 
geon to the Hospital of the Incurables in 1697. His chief work was 
De aure humana tractatus (1705). 

Gaetano Tacconi (1689-1782), a native of Bologna, succeeded Val- 
salva as professor, and was surgeon to the hospital Santa Maria. He 
wrote Notizia della ferita e della cura chirurgica seguita, etc. (1738), and 
De raris quibusdam herniis, etc. (1751). 

Giovanni Ambrogio Bertrandi (1723-65), son of a surgeon, studied at 
Turin and Paris, and in 1758 succeeded Lotteri as professor of surgery 
at Turin. His principal work is his Trattato delle operazioni di chi- 
rurgia (2 vols., 1763), which passed through several editions and was 
translated into French and German. His collected works, Opere 
anatomiche e cerusiche, were published after his death in fourteen 
volumes (1786-1802). 

At the beginning of the eighteenth century there were few educated 
surgeons in London, and still fewer in the provincial towns ; there was 
no special instruction in surgery to be obtained except through appren- 
ticeship ; and the facilities for studying anatomy were extremely limited.' 
When the monasteries were broken up by Henry VIII. the hospitals, 
which had previously belonged to the Church, became the property of 
the government. St. Bartholomew's was refounded in 1544, and placed 
under the superintendence of Thomas Vicary. This hospital had one 
physician and three surgeons, and these allowed their pupils and appren- 
tices to attend and witness the practice. In 1662 there is mention of 
the presence of such students, but no formal system of lectures or teach- 
ing seems to have existed until after 1734, when leave was granted for 

' See The present state of chyrurgery. by T. T>. (London, 1703), in which, among other 
charlatans, reference is made to " The Unborn Doctor who cut off a vast number of 
women's breasts without loss of blood." 
Vol. I.— 6 



82 THE HISTORY AND LITERATURE OF SURGERY. 

any of the surgeons or assistant surgeons to read lectures in anatomy in 
the dissecting-room of the hospital, and in 1763 a course of lectures on 
surgery was commenced by Percival Pott. 

At St. Thomas's Hospital the first mention of an apprentice in the 
books is in 1561. The Barber Surgeons' Company was dissatisfied with 
the teaching in St. Bartholomew's and St. Thomas's hospitals, as it was 
losing money thereby, and in 1695 it made a special investigation into 
the complaints as to the manner of teaching in these hospitals, the sur- 
geons to which declared that they had never taken an apprentice for a 
less term than seven years, but that some of the apprentices of other sur- 
geons were allowed at times to witness their practice. In 1702 the gov- 
ernors of St. Thomas's Hospital took the matter of teaching into their 
own hands, and passed a law forbidding pupils or surgeons to dissect 
without permission of the treasurer. In 1703 it was resolved that 
no surgeon should have more than three " Cubbs ;" in 1758 this term 
was altered to that of " Dressers." Lectures on anatomy and surgery 
began with Cheselden about 1720, and the Anatomical School may be 
said to have been fairly established about 1780.^ 

At the London Hospital the entry of the first student was in 1742, 
two years after the commencement of the hospital, and the Medical 
School was fully organized upon the model of the Edinburgh Faculty 
in 1785. 

In the Orders of St. Bartholomew, dated 1633, it is directed " that no 
chirurgeon, or his man, doe trepan the head, dismember, or perform any 
great oper'con, but with the approbation or by the direction of the doc- 
tor." Special operators were appointed to cut for the stone at the hos- 
pitals, a Mr. Mullins doing this for St. Bartholomew's and St. Thomas's. 

The Medical School of Guy's Hospital dates from 1769, in which 
year a resolution was passed by the governors that all surgeons of the 
hospital should occasionally give lectures to the pupils. It is also noted : 
" No persons are to be entertained as pupils but such as have served five 
years to a regular Surgeon or Apothecary." At this time the schools of 
Guy's and of St. Thomas's were united, the surgical lectures being given 
at St. Thomas's and the medical at Guy's, and the two were known as 
the " United Hospitals." ^ 

The ill-assorted union of surgeons and barbers formed by the act of 
1540 was by no means harmonious, but the surgeons were unable to get 
rid of the barbers until 1745, when they agreed with Mr. Ranby, Serjeant 
surgeon to the king, that he should procure the act of Parliament desired, 
and that in return he should be made a member and be elected as master. 
The act of 1745, incorporating the " Masters, Governors, and Common- 
alty of the Art and Science of Surgeons of London," provided that it 
should be governed by a " court of assistants, composed of twenty-one 
members, whose office was for life, and who filled their own vacancies 
by election from the freemen of the company." Ten of this court of 
assistants were to be " examiners," whose office was also for life, and it 
was a penal offence for any one to practise surgery in London or within 
seven miles of the same without having been duly examined and licensed 

1 See Prospectus, 1877-78, p. 11. 

'' See A Biographical History of Quy's Hospital, by S. Wilks and G T Bettanv 
(London, 1892). ' ' 



THE HISTORY AND LITEBATUBE OF SUBGEBY. 83 

except that tlie rights of members of the College of Physicians to do so 
were not to be interfered with. The surgeons on their separation from 
the barbers took nothing with them except the Arris and Gale bequests ; 
the hall, library, and plate remained with the barbers, and the new com- 
pany had to provide a building for itself. 

The condition of the company in 1790, as stated by Mr. Gunning, 
the master of the company, in his address at the close of his term of 
office, was as follows : " You have a theatre for your lectures, a room for 
a Library, a committee-room for your Court, a large room for the recep- 
tion of your committees, together with the necessary accommodation for 

your Clerk Your theatre is without lectures, your library room 

without books is converted into an office for your clerk, and your com- 
mittee room is become his parlour, and is not always used even in your 
common business, and when it is thus made use of it is seldom in a fit 
and proper state." The next thing that appears in its history is a charter 
by George III., dated 1800, for consolidating the Royal College of Sur- 
geons of London, in the preamble of which it is stated that " we are 
informed that the said Corporation of Masters, Governors, and Com- 
monalty of the Art and Science of Surgery of London hath become 
and is now dissolved." This charter of 1800 simply reiterates the act 
of 1745. 

Turning now to Scotland, we find that, in 1694, Dr. Archibald Pitr- 
cairn returned to Edinburgh from Leyden and endeavored to establish a 
medical school, which he intended, if possible, should surpass that of 
Leyden ; and his first step was to induce a surgeon named Monteith to 
apply to the town council for a grant of dead bodies. As soon as the 
other surgeons heard of this, they also applied for the same privilege. 
The privilege granted to the surgeons had a clause to the effect " that 
the petitioners shall before the term Michaelmas, 1697, build, repair, and 
have in readiness one anatomical theatre, where they shall once a year 
(a subject offering) have one public anatomical dissection, as much as 
can be shown upon one body, and if the failzie, this presents to be void 
and null." This condition was complied with, and as the grant required 
that the body should be buried within ten days, the surgeons selected 
ten of their number, termed " operators," each of whom lectured one day 
on certain specified parts. In 1705 this system was changed, and one 
surgeon performed , the duty, while the town council made this same sur- 
geon professor of anatomy in the university. This was the commence- 
ment of the Medical School, although it was not until 1726 that it was 
fully formed through the influence of John Monro, an army surgeon 
who had settled in Edinburgh in 1700. 

The leading surgeon in England in the first half of the eighteenth 
century was William Cheselden (1688-1752), a pupil of William Cowper, 
who began to lecture on anatomy in 1711 in his own house, and continued 
his teaching afterward at St. Thomas's Hospital, to which he was 
appointed assistant surgeon in 1718 and surgeon in 1719. In 1723 
he published his Treatise on the high operation for the stone. Soon after 
he gave up this and perfected his " lateral operation for the stone," an 
improvement on the method of FrSre Jacques and Rau, which soon 
became famous. He published a paper in the Philosophical Transactions 
on the formation of artificial pupil, which operation he was the first to 



,84^ THE HISTORY AND LITERATURE OF SURGERY. 

perform. In 1733 he became surgeon to St. George's Hospital at its 
foundation, retired from St. Thomas's in 1738, and was one of the last 
wardens of the Barber Surgeons' Company immediately before the sepa- 
ration of the surgeons and barbers, which took place in 1744-45. 

His pupil, Samuel Sharp (1700-78), was elected surgeon to Guy's 
Hospital in 1733. His Treatise on the operations of surgery (London, 
1739; 10th ed., 1782) and his Critical inquiry into the present state 
of surgery (London, 1750 and 1761, and translated into French, Spanish, 
and German) were celebrated in their day, and the Critical inquiry is 
still a most interesting book to the surgeon. He devised the cylindrical 
form of the crown of the trephine at present used, and contributed to 
the knowledge of the anatomy of hernia. 

William Bromfield (1712-92), surgeon to St. George's Hospital and 
surgeon to the king, published his Chirurgical observations and cases, in 
two volumes, in 1773. These contain a number of valuable improvements 
in surgical methods, particularly as to bilateral lithotomy and the com- 
pression of the subclavian artery above the clavicle on the first rib. He 
also clearly points out the proper manner of ligating the artery in ampu- 
tations, using the tenaculum to draw out the vessel, so that the nerve and 
other tissues should not be included, but he used a flat ligature. That 
he was a cool operator is shown in a case of lithotomy which he reports 
in the second volume at page 266, in which the intestines protruded into 
the bladder, and in which he first extracted three stones and then returned 
the intestines, with result of a perfect cure. 

William Beckett (1684-1738), a London surgeon, wrote Practical 
surgery illustrated and improved : being chirurgical observations .... made 
at St. Thomas's Hospital (London, 1740, 8vo), also A collection of chirur- 
gical tracts (London, 1740, 8vo), including a paper on new discoveries 
relating to the cure of cancers, published by him in 1711. 

Benjamin Gooch, a surgeon of the Norfolk and Norwich Hospital in 
1771, published a volume of Cases and practical remarks in surgery 
(London, 1758), and a collective edition of his works appeared in three 
volumes (London, 1792). He taught that in case of a wound of an 
artery ligatures must be applied both above and below the wound. 

John Douglas (?-1743) was a Scotch surgeon who gave private lec- 
tures on surgery and anatomy in London about 1720, and in the 
same year published an account of the performance of the high opera- 
tion for the stone under the title of Lithotomia Douglassiana. He was 
conceited and quarrelsome, and published two abusive pamphlets on 
Cheselden, by whom he was completely overshadowed. 

His brother, James Douglas (1675-1742), was a physician who settled 
in London about 1700, and was a distinguished anatomist and obstetrician. 
He published a Description of the peritoneum (London, 1730, 4to), in 
which he described the fold of the peritoneum which is still known by 
his name. 

To the first half of this century belongs one of the greatest itinerant 
quacks known to history — viz. John Taylor (1708-67), who styled him- 
self " Chevalier, ophthalmiater pontifical, imperial, and royal." He was 
born in Norwich, and in 1727 published a pamphlet on the mechanism of 
the eye and on cataract. This he dedicated to Cheselden, from whom he 
acknowledges that he had learned all that he knew about the matter and 



THE HISTORY AND LITERATURE OF SURGERY. 85' 

while the work was boastful, yet it was not more so than some other pub- 
lications of that day. Soon after this period he appears to have given up 
all idea of respectable practice, and travelled far and wide over Europe, 
advertising himself extensively in every place that he came to, and 
publishing for the same purpose a large number of pamphlets referring 
to his wonderful cures. His autobiography, published in three volumes 
(London, 1762), is one of the curiosities of literature. 

The principal English surgeon in the middle of the century was 
Percival Pott (1713-88), who became assistant surgeon of St. Bartholo- 
mew's Hospital in 1745 and surgeon in 1749. His contributions to 
surgery were numerous and important, especially those on hernia, 
injuries to the head, hydrocele, and the disease of the spine still known 
by his name as " Pott's disease." His Treatise on ruptures was pub- 
lished in 1756, his Practical remarks on the hydrocele, in 1762, and his 
Remarks on that kind of palsy of the lower limbs which is frequently found 
to accompany a curvature of the spine, in 1779. His Chirurgical loorks 
appeared in 1771, and there were four later editions, besides German, 
French, and Italian translations. 

Alexander Monro (1697-1767), a pupil of Cheselden and of Boei^ 
haave, became the first professor of anatomy in the University of Edin- 
burgh in 1725 ; he also lectured on surgery and made great use of com- 
parative anatomy. He founded the Royal Infirmary and gave clinical 
lectures on surgery, and was one of the best surgeons of his time. His 
writings relate chiefly to anatomy, but he also wrote important papers on 
aneurism, cataract, hernia, etc. He first tried to cure hydrocele by the 
injection of wine. His son, Alexander Monro [secundus] (1733-1817), 
succeeded him as professor of surgery, and held the chair until 1810, 
when he gave it over to his son of the same name, Alexander Monro 
[tertius] (1773-1859), who resigned in 1846, the professorship having 
thus been held by the three Monros for one hundred and twenty-one 
years. Although the chair was thus, after a fashion, hereditary, the 
talent did not descend to the third generation. 

The next name to be mentioned is that of a man whose works mark 
an epoch in the development of surgery — John Hunter (1728-93), the 
youngest son of a Scotch farmer. His brother William, ten years older 
than himself, having received an excellent education according to the 
pattern of that time, settled in London and began to lecture on anatomy 
and surgery in 1746. In 1748, John Hunter, a rough, ignorant youth, 
decidedly addicted to low company and amusements, and not having 
shown the slightest taste for study, joined his brother, and was employed 
by him as an assistant in the dissecting-room which he had just estab- 
lished. He soon showed that he had found his proper field of activity, 
and after one year's experience was able to take charge of the pupils 
and to direct their work. William Hunter was a good classical scholar 
and a cultivated and polished man of the world, being in all these 
respects a complete contrast to his brother, who decided in favor of 
surgery as a career, and studied under Cheselden and Percival Pott. 

The brothers entered into partnership in 1754, John devoting him- 
self mainly to anatomy and to physiological experimentation. He also 
began to deliver lectures, but he was by no means attractive as either 
a writer or a speaker, and in the latter capacity his audience never 



86 THE HISTORY AND LITERATURE OF SURGERY. 

amounted to twenty persons. In 1761 he joined the army, going to 
the Spanish Peninsula, and remained with it until 1763, during which 
time he collected the observations contained in his treatise on gunshot 
wounds. On his return he began to teach anatomy and surgery to 
private pupils or apprentices, in which undertaking he was aided by his 
election as surgeon to St. George's Hospital in 1768. The remainder of 
his life was spent in this work, in investigations, and in the formation 
of the splendid museum which is now under the charge of the Royal 
College of Surgeons of London. 

The name of John Hunter is familiar to all surgeons mainly through 
his recommendation that in cases of aneurism due to disease of the artery 
the artery should be tied in the sound parts between the aneurism and 
the heart ; and aside from this and his great museum, very few persons, 
except those who have prepared Hunterian orations or studied them, 
could probably state with any clearness what it was that he did to 
acquire the reputation which he possesses. His work on comparative 
anatomy was the result of the dissection of over five hundred species 
of animals, in the course of which he made innumerable discoveries and 
anticipated many comparatively recent observers ; and in comparative 
physiology it was even greater, being so far in advance of his times that 
it was not comprehended. 

The treatise on Blood, Inflammation, and Gunshot Wounds is usually 
considered Hunter's greatest work and as embodying the results of the best 
part of his researches. This work was completed and given to the press 
during the last year of Hunter's life, and was not published until 1794. 

The merit of Hunter's operation for aneurism does not, as Guthrie 
remarks, lie in the operative process, but in the principles upon whicli 
it is founded. The dangers arising from the application of the method of 
Antyllus to aneurisms produced by disease of the artery were in part due 
to the danger from hemorrhage when the artery, in a state of disease, is 
ligated, and in part to the suppuration and ulceration which followed the 
opening of the sac. But Hunter, reasoning upon experiments made by 
him in removing portions of the coat of arteries, and also upon the 
results which he had observed with regard to the establishment of a 
collateral circulation in cases where an artery had been obstructed, said : 
" If the artery, however, cannot be tied above the aneurism in the ope- 
ration, where can it be tied if the limb be amputated ? Why not tie it 
up higher in the sound parts, where it is tied in amputation, and pre- 
serve the limb?" 

He first performed this operation in 1785, placing four ligatures on 
the artery with various degrees of tightness. The patient was cured of 
the aneurism, but died of other complications fifteen months afterward. 
In the second operation he applied only one ligature. Hunter probably 
was not aware of the full scope and value of his suggestion. He con- 
sidered that the arteries which would admit of the operation were the 
carotids above the sternum, any of the branches of the external carotids, 
the subclavian after having passed the scaleni muscles, and the crural 
after having passed Poupart's ligament and given oif the large muscular 
artery. He did not think the subclavian should be tied in axillary 
aneurism, because he would doubt as to the soundness of the artery, 
and the same with the femoral where it passes under Poupart's ligament. 



THE HISTORY AND LITERATURE OF SURGERY. 87 

His plan was opposed by Pott and Bromfield, the latter of whom said : 
" An extravagant proposition has been suggested by some people to tie 
up the principal trunk of an artery in the extremities. I once saw an 
attempt of this kind in a true aneurism of the ham, in which I shall 
only remark that the patient died ; and I do believe that the embarrass- 
ments which occurred, as well as the event of the operation, will deter 
the gentleman who performed it from making a second attempt in a sim- 
ilar case." Hunter, after quoting this, says : " Now, unfortunately either 
for Mr. Bromfield or myself, this is the very case from which I have 
formed favorable ideas of the success of future operations of a similar 
nature." '■ Pott, writing in 1777, said : " As far as my observation and 
experience go, the operation for aneurism in the femoral and popliteal 
arteries, however judiciously performed, will not be successful ; that is, 
will not save the patient's life. I have tried it myself more than once 
or twice. I have seen it tried by others ; but the event has always been 

fatal Nor have I ever seen any other operation that that of 

amputation which has preserved the life of the patient." 

John Hunter was a tremendous worker. His labors were almost 
incessant. It is probable that his ignorance of what had been done by 
others was not so great as most persons have inferred from the fact that 
he rarely quotes or refers to others. It should be remembered that he 
was for a long time associated with his brother, who was certainly well 
acquainted with medical literature, and that he daily met men of culture 
and information, from whom he must have learned a certain amount of 
what was going on elsewhere. Some of his greatest work was effected 
through his pupils, Jenner, Abernethy, Astley Cooper, Physick, Ever- 
ard Home, and others, all of whom were trained by him and perpet- 
uated and expanded his teachings. Since his day mere mechanical dex- 
terity, with some knowledge of ointments and plasters, is no longer 
thought sufficient for the stock in trade of a surgeon. The peculiar 
combination of work in anatomy, pathology, and surgery pursued by 
Hunter has been accepted to a large extent in England since his time as 
a model of training for a surgeon, and most of the modern leading sur- 
geons have been in their younger days teachers of anatomy and of path- 
ology ; which fact has exercised a great influence upon the development 
and methods of teaching of surgery in England. 

The successor of Hunter in English surgery was his pupil and enthu- 
siastic admirer, John Abernethy (1764-1831). He was elected assistant 
surgeon to St. Bartholomew's in 1787 on the retirement of Mr. Pott, and 
then began to give private lectures on anatomy at his own house, and his 
success was such that the governors of St. Bartholomew's were induced 
to build a lecture theatre, where in 1791 he began to lecture on anatomy, 
physiology, and surgery. 

Abernethy was the first to ligate the external iliac artery for aneur- 
ism, in 1796, and in 1798 he ligated the common carotid for hemor- 
rhage. In 1793 he performed neurectomy for neuralgia of the arm 
commencing in the finger, and proved that after the removal of half an 
inch of the nerve reunion occurred and the skin of the finger resumed its 
natural sensibility.^ He also introduced an improvement in the opening 

^ Works of John Hunter, edited by J. F. Palmer (London, 1837, vol. i. p. 547). 
^ See his Surgical Works (new edition, vol. ii., 1817, p. 205). 



88 THE HISTORY AND LITERATURE OF SURGERY. 

of lumbar abscesses by a method of incision which should admit the 
least possible amount of air. As he grew older he ceased to operate, 
and devoted himself more to the treatment of the general health of his 
patients. The work by which he is best known is his Essay on the 
constitutional origin of local diseases. Abernethy's reputation was not 
due to his books so much as it was to his lectures, which were dramatic 
in character, and given with certain eccentricities of manner and speech 
which considerably contributed to his reputation. 

Henry Cline (1750-1827) was a pupil of Hunter, and became sur- 
geon of St. Thomas's Hospital and president of the Eoyal College of 
Surgeons in 1823. He was lecturer on anatomy and surgery in the 
early part of the eighteenth century in the Aldersgate School, and con- 
tributed largely to the spread of the new ideas of Hunter. He wrote 
no special treatises, but had a number of distinguished pupils. 

Sir William Blizard (1743-1835), a pupil of Hunter, became sur- 
geon of the London Hospital in 1780 and founder of its medical 
school, to the cost of which he contributed largely. He was twice 
president of the College of Surgeons and founded the Jacksonian prize. 
He was one of the first to ligate the subclavian and the first to ligate the 
superior thyroid artery. His publications are chiefly in journals. 

Sir Everard Home (1763-1832), the son of an army surgeon, was a 
pupil of John Hunter, who married his sister. He served for a short 
time in the army, returned to London and became Hunter's assistant, 
was appointed assistant surgeon to St. George's Hospital in 1787, and 
surgeon to the same in 1793, after Hunter's death. He was one of 
Hunter's executors and edited his works, was made a baronet in 1813, 
and resigned his position at St. George's in 1827. He was a voluminous 
writer, treating on strictures of the urethra, on ulcers, on diseases of the 
prostate, on comparative anatomy, etc., but lost his reputation as an 
author on account of the fact that he destroyed the greater part of the 
large collection of Hunter's manuscripts, of which he had obtained tem- 
porary possession, and which he used in preparing his own papers. 

Other London surgeons of this century who should be mentioned are 
Sir Caesar Hawkins, surgeon to King George II. and King George III., 
and surgeon of St. George's Hospital from 1735 to 1774 ; Thomas 
Gataker, surgeon of St. George's Hospital, who died in 1769 ; Joseph 
Warner (1717-1801), a pupil of Sharp, who became surgeon of Guy's 
Hospital in 1748, first ligated the common carotid in 1775, and whose 
Cases in Surgery (London, 1754; 4th ed., 1784) are still worth reading; 
and Sir James Earle (1755-1817), surgeon of St. Bartholomew's Hos- 
pital, who is best known by his Treatise on hydrocele (London, 1791) and 
Observations on the operation for the stone (London, 1793). 

Among the distinguished provincial surgeons of this period may be 
mentioned Alanson, Park, White, Mynors, and Hey. 

Edward Alanson (1747-1823) was a pupil of John Hunter, and sur- 
geon of the Royal Infirmary at Liverpool from 1770 to 1794. He 
published Practical observations on amputation and the after-treatment 
(London, 1779), in which he recommended a method for obtaining a 
more complete covering for the end of the bone by cutting the mus- 
cles from below upward. 

Henry Park (1744-1831) was a student of Pott and Le Cat, and was 



THE HISTORY AND LITEBATUBE OF SURGERY. 89 

surgeon of the Royal Infirmary at Liverpool from 1767 to 1798. His 
name is connected with the history of resection of the knee and elbow. 

Charles "White of Manchester published his Cases in Surgery in 1770, 
and first excised the head of the humerus in 1768. 

Robert Mynors (1739-1806), a surgeon of Birmingham, published 
his Practical observaiions on amputation in 1783, and his History of the 
practice of trephining the skull, etc. in 1785. 

William Hey (1736-1819), a distinguished surgeon of Leeds, pub- 
lished in 1803 his Practical Observations in Surgery, which passed 
through two later editions, and is still worthy of consultation. He 
described and named fungus hcematodes. His name is connected with 
the form of saw devised by him for use in case of fracture of the skull, 
and with a mode of partial amputation of the foot. 

At the end of the century the leading surgeons in Edinburgh were 
Benjamin and John Bell. 

Benjamin Bell (1749-1806) was a pupil of Monro, and became a sur- 
geon of the Royal Infirmary in 1772. In 1778 he published A treatise 
on the theory and management of ulcers, etc., which went through nume- 
rous editions and translations. His System of surgery (6 vols., Edin- 
burgh, 1783-87) also passed through many editions, and Avas trans- 
lated into Grerman and French, being the favorite systematic treatise for 
the next twenty years. He insisted strongly on the importance of 
saving skin in amputations and operations for the removal of tumors, 
in order to leave as little as possible of the surface of the wound exposed. 

John Bell (1765-1820) graduated in medicine in Edinburgh in 1779, 
and in 1790 opened a private school for anatomy, surgery, and obstetrics. 
He was ambitious and energetic, and unsparing in his criticisms of his 
seniors, Monro and Benjamin Bell, thus causing opposition to his school, 
which, however, was popular and successful. His brother Charles was 
of great assistance to him in this enterprise. He published a treatise on 
anatomy which went through many editions : Discourse on the nature 
and cure of wounds (Edinburgh, 1795, with several editions and trans- 
lations) and The Principles of surgery (3 vols., London, 1801-08, 4to), 
remarkable for the beauty of its engravings. He was the leading ope- 
rating surgeon in Edinburgh for nearly twenty years. As the result of 
a bitter controversy with Gregory the number of surgeons at the Royal 
Infirmary was in 1800 limited to six, and Bell, with others, was excluded, 
and thus lost the opportunity for clinical teaching. 

The story of the rise and progress of surgery in Ireland is told in the 
History of the Royal College of Surgeons in Ireland and the Irish Schools 
of Medicine, by Charles A. Cameron (Dublin, 1886). 

In 1446, King Henry YI. established, by royal charter, a fraternity 
or guild of barbers for the promotion and exercise of the art of chirurgery. 
In 1572, Queen Elizabeth granted a second charter to the barbers and 
surgeons, ordering that they should be called the " Master Wardens and 
Fraternity of Barbers and Chirurgeons of the Guild of Saint Mary or 
Magdalene in our city of Dublin," and a third charter was granted in 
1687 by James II., giving them full power of the guild over barbers 
within six miles of Dublin. There were, however, a certain number of 
surgeons who had no connection of any kind with the company, being 
army surgeons, or men of liberal education who had studied in the uni- 



90 THE HISTORY AND LITERATURE OF SURGERY. 

versities. In 1745 the company began to disintegrate, and in 1784 the 
union between the barbers and the surgeons was practically dissolved by 
the creation of the Royal College of Surgeons in Ireland. The beginning 
of teaching in Dublin is due to Sir Patrick Dun (1642-1713), president 
of the College of Physicians in Ireland, who left a bequest for " one or 
two Professors of Physick to read publick Lectures and make publick 
Anatomical dissections of the several parts of the human Body or Body's 
of other animals, to read Lectures of Osteology, Bandages, and operations 
of Chirurgery, to read Botanic Lectures, Demonstrate Plants publickly, 
and to read Publick Lectures on Materia Medica, for the Instruction 
of Students of Physick, Surgery, and Pharmacy." The teaching did 
not actually begin until 1744. The first surgical work published in 
Ireland appears to be J. Concise and Impartial Account of the Advan- 
tages arising to the Public from the general use of a New Method of Am- 
putation (Dublin, 1763, pp. 13). The second was Observations on Wounds 
of the Head (Dublin, 1776, pp. 177). This was published anonymously, 
but appeared in a second edition in 1778 under the name of the author, 
"William Dease (1752-98), who was one of the most energetic founders 
of the Royal College of Surgeons, and one of the first to lecture in it. 
He was a very successful teacher, and in addition to his work on wounds 
of the head he published An Introduction to the Theory and Practice of 
Bwrgery (London, 1780, 8vo) and a work on midwifery which became a 
popular text^book. 

In 1765, Sylvester O'Halloran (1728-1807), a surgeon of Limerick, 
who had studied in Paris, London, and Leyden, published at London 
A Complete Treatise on Gangrene and Sphacelus ; with a new Method of 
Amputation, which was a valuable contribution to the literature of these 
subjects. 

The Nineteenth Century. 

The salient points in the history of surgery in the nineteenth century 
are the discovery of anaesthetics ; the establishment of aseptic and anti- 
septic surgery upon the scientific foundation of the new science of bacteri- 
ology ; the development of conservative surgery in the treatment of diseases 
and injuries of the extremities and of plastic and orthopaedic surgery into 
a specialty ; the rise and progress of abdominal and intracranial surgery ; 
the entrance of two new nations, the United States and Russia, into the field 
of surgical discovery, literature, and teaching ; the change in the methods 
of educating surgeons ; the formation of surgical societies and associations ; 
and the cosmopolitan character of the art developed by rapid international 
communication and by periodicals. The founding of museums like those 
of Hunter and Dupuytren, the removal of restrictions on the study of 
anatomy, the great advances made in pathological anatomy and experi- 
mental pathology, and the development of ophthalmology, otology, 
gynaecology, dermatology, and laryngology into their present highly 
specialized forms, have also exerted a strong influence upon surgery and 
the work of the general surgeon. 

"With the increasing accumulation of the people in cities have come 
increased demands and opportunities for surgeons, for increase of hospi- 
tals and medical schools, for skilled nursing, ingenious mechanics for the 
making of instruments and apparatus, and, in short, for many means of 



THE HISTORY AND LITERATURE OF SURGERY. 91 

carrying out suggestions for improvements through the aid of competent 
assistants. 

More progress in the art has been made since 1800 than had been 
made in the two thousand years preceding that date, and this has been 
largely due to work done in the dissecting-room and in the laboratory. 
Consider for a moment some of the differences between the resources of 
the surgeon of 1800 and those of the surgeon of the present day. The 
surgeon of 1800 had little more knowledge than had Hippocrates of the 
chief causes of danger after operations, such as suppuration, pysemia, or 
tetanus, and groped wildly for means to avoid them. He had no clinical 
thermometer, and could only guess at temperature and fever ; no hypoder- 
mic syringe ; no ansesthetic ; no definite knowledge of the importance of 
blood-saving or of the best means of doing it. He knew nothing of plastic 
surgery, of tenotomy, of the ophthalmoscope, or of the use of the micro- 
scope in diagnosis, and had only just learned how to ligate arteries and 
to treat ordinary wounds in a simple and sensible way. The really great 
surgeon of that day who was bold, cool, and skilful could perform most 
of the great operations, such as amputation, ligature of large arteries, 
removal of tumors, Csesarean section,, and the like, but such men were 
few and far between. 

At the beginning of the century London was the centre of surgical 
improvement and of surgical teaching, and the leading surgeons at that 
time were Abernethy, Cline, Blizard, Home, Astley Cooper, Lawrence, 
and Wardrop. The first four of these have been referred to in a pre- 
vious section. 

Astley Paston Cooper (1768-1841), a native of Norfolk, was appren- 
ticed in 1784 to his uncle, William Cooper, surgeon to Guy's Hospital, 
and was soon transferred to Cline, then surgeon at St. Thomas's. He 
attended John Hunter's lectures and spent one winter at the Edinburgh 
Medical School, was appointed demonstrator of anatomy at St. Thomas's 
in 1789, and two years later became joint lecturer with Cline in anatomy 
and surgery. In 1800 he was appointed surgeon to Guy's on the resig- 
nation of his uncle. In 1 805 he ligated the common carotid for aneurism, 
and in 1817 the abdominal aorta. In 1820 he performed a simple opera- 
tion on King George IV., which resulted in his being made a baronet. 
In 1826 he resigned his lectureship at St. Thomas's and induced the for- 
mation of a separate medical school at Guy's, in which his pupil, Aston 
Key, lectured on surgery, and his nephew, Bransby Cooper, on anatomy. 
He was an extremely skilled anatomist, and some of his most valuable 
contributions are connected with his work in this direction. Among them 
may be mentioned his treatises on hernia (in two parts, 1804-07), the 
second edition of which appeared in 1827, the illustrations to which are 
said to have been so expensive that he lost a thousand pounds by the 
publication. His book on Dislocations and Fractures of the Joints 
was published in 1822; his Lectures on the Principles and Practice 
of Surgery, with additions by Tyrrell, in three volumes, in 1824-27 : 
the eighth edition of this appeared in 1837 ; and his Illustrations of Dis- 
eases of the Breast, Part I., in 1829 ; his observations on the Structure 
and Diseases of the Testes in 1830 ; and his work on the Anatomy of 
the Breast in 1840. He seems to have read little, his books contain few 
references to the work of other men, and his reputation and influence 



92 THE HISTORY AND LITERATURE OF SURGERY. 

were due more to his personality and his great skill as an operator than 
to his contributions to science or practice. 

William Lawrence (1783-1867), the son of a surgeon, was a pupil of 
Abernethy and his demonstrator of anatomy for twelve years. He 
became a member of the College of Surgeons in 1805, won its prize for 
an essay on hernia in 1806, was appointed assistant surgeon to St. Bar- 
tholomew's Hospital in 1813, and in 1815 became professor of anatomy 
and physiology at the College of Surgeons. His lectures were considered 
to flavor of infidelity, and led to a sharp controversy, which ended by his 
recanting the objectionable opinions and withdrawing his book. On the 
History of Man, from sale as far as he could. He was connected with 
the Aldersgate Medical School, and in 1823 succeeded Abernethy as 
lecturer on surgery at St. Bartholomew's. His principal contributions 
to surgical literature are his Treatise on Diseases of the Eye (1833) and 
his Lectures on Surgery, published in 1863. He was a skilled anatomist, 
an eloquent lecturer, and an erudite author. 

James Wardrop (1782-1869), a native of Scotland and educated in 
Edinburgh, came to London in 1809. In 1826 he founded a hospital 
under the title of the " West London Hospital of Surgery," and in the 
same year, in conjunction with Mr. Lawrence, gave a course of lectures 
at the Aldersgate Street School. His abusive articles in The Lancet in 
1826-27 probably prevented him from having any official connection 
with the colleges. In 1828 he was made surgeon to the king. He 
wrote for The Lancet (1834, vol. ii.) a series of grossly personal and 
abusive papers entitled " Intercepted Letters," purporting to be written 
by Halford, Brodie, McMichael, and others, after which the heads of 
the profession in London had as little as possible to do with their 
author. In 1835 he joined the Hunterian School of Medicine and 
gave a course of lectures on surgery. His best-known work is that on 
the Morbid Anatomy of the Eye. His name in the history of surgery is 
chiefly connected with the operation first proposed by Brasdor for the 
cure of aneurism by placing a ligature on the distal side of the tumor, 
which operation Mr. Wardrop performed successfully in two cases of 
aneurism of the carotid artery, and in one case of aneurism of the innom- 
inate artery, in which he tied the subclavian. 

The following surgeons also belong to the early part of the centuiy : 

Joseph C. Carpue (1764-1846), who in An Account of two Successful 
Operations for Restoring a Lost Nose, etc. (London, 1816, 4to), intro- 
duced rhinoplasty' by the Indian method, and recalled attention to the 
high operation for stone in his excellent historical sketch. The History 
of the High Operation for the Stone (London, 1819). 

Samuel Cooper (1780-1848), surgeon of the University College Hos- 
pital from 1831 to 1848, published his Surgical Dictionary in 1809, the 
first comprehensive and complete work of the kind in existence, and the 
continued popularity of which is shown by the fact that its eighth edition 
was published in 1861-72. Every edition is valuable to the student of 
the progress of surgery in the nineteenth century. 

Alexander Copland Hutchinson, a naval surgeon, published Practical 
Observations on Surgery in 1816 (2d ed. 1826), and Some further Obser- 
vations on the subject of the proper period for Amputating in Gunshot 
Wounds, etc., in 1817. 



THE HISTORY AND LITERATURE OF SURGERY. 93 

Charles Aston Key (1793-1849), a pupil of Astley Cooper, whose 
niece he married, became demonstrator of anatomy at St. Thomas's 
Hospital in 1820, assistant surgeon to Guy's Hospital in 1821, surgeon 
to the same in 1824, and professor of surgery in its school in 1825. He 
ligated the subclavian artery in 1826, and tied the carotid for aneurism 
in 1830 ; introduced the use of the straight staff in lithotomy, and the 
method of dividing the stricture external to the sac in strangulated 
hernia, and was one of the most popular teachers in London. 

From 1820 to 1835 the leading London surgeons, in addition to those 
already referred to, were Brodie, Bell, and Travers. 

Sir Benjamin Collins Brodie (1783-1862) was a native of Wiltshire, 
England. He studied in London, and began to assist in teaching at the 
Windmill Street School in 1805, when he was twenty-two years of age. 
In 1803 he became the pupil of Sir Everard Home, and in 1808 assistant 
surgeon at St. Thomas's Hospital, where, in 1822, on the death of Mr. 
Griffiths, he became full surgeon, from which position he retired in 1840. 
He devoted himself lai-gely to physiological experiments, some results of 
which appeared in the celebrated Croonian Lecture, delivered in 1810, on 
the influence of the brain on the action of the heart, in which he reported 
the results of the use of the woorara poison, and in a paper published in 
1814 on The Influence of the Pneumogastric on the Secretions of the Stom- 
ach. Of his surgical writings, the first, and perhaps the most important, is 
his Pathological and Surgical Observations on the Diseases of the Joints, 
published in 1818, and appearing in a fifth edition in 1851. His lectures 
On Diseases of the Urinary Organs appeared in 1832, a fourth edition 
being issued in 1849. In 1846 he published a volume of lectures on 
various subjects in pathology and surgery. His complete works, with 
an autobiography, are published in three volumes (8vo, London, 1865). 
He devoted himself to the scientific side of surgery rather than to opera- 
tions, although he was a very successful operator, and for over thirty 
years was recognized as the head of the medical profession in London. 

Sir Charles Bell (1778-1842) was a younger brother of John Bell of 
Edinburgh, under whom he studied and whom he soon began to assist in 
the teaching of anatomy. In 1804 he went to London, where he began 
to teach in his own house in 1807, after which he associated himself with 
Mr. Wilson in the Great Windmill Street School, where he came into com- 
petition as a teacher with Cline, Cooper, and Abernethy, and met with 
great success. In 1812 he began to deliver clinical lectures in the Mid- 
dlesex Hospital, to which he was appointed surgeon in 1814. In 1836 
he accepted the chair of surgery in the University of Edinburgh, which 
he held until his death. His publications were voluminous, and include 
his System of Operative Surgery (2 vols., 1807-09), his paper on Gunshot 
Wounds (in 1814), his Surgical Observations (2 vols., London, 1816-18), 
and his Illustrations of the Great Operations in Surgery, etc. (in 1821). 
His fame, however, is mainly due to his papers relating to the ner- 
vous system, the result of careful and long-continued experimental 
work. His Idea of a New Anatomy of the Brain, printed in 1811, is a 
pamphlet of 36 pages which forms an epoch in the history of discoveries 
relating to the structure and functions of that organ. He was a skilled 
artist, a dexterous operator, and a conscientious and popular teacher, 
whose fame has increased instead of diminishing since his death. 



94 THE HISTORY AND LITEBATUBE OF SUBOEBY. 

Benjamin Travers (1783-1858) was a pupil of Astley Cooper, pro- 
sector of anatomy at Guy's Hospital, and surgeon of St. Thomas's Hos- , 
pital in 1815. He was a skilled ophthalmologist, and his Synopsis of the 
Diseases of the Eye (1820) was the best systematic treatise on that subject 
which had yet appeared in English. His tastes led him to the scientific 
rather than to the practical aspect of surgery, and his treatises on Con- 
stitutional Irritation (1824), A further Inquiry concerning Constitutional 
Irritation and the Pathology of the Nervous System (1834), and The 
Physiology of Inflammation (1844) are specimens of physiologico-path- 
ological investigation of the highest order of merit. He contributed 
some valuable papers on aneurism and the ligature of arteries to the 
Medico-chirurgical Transactions, and one on wounds of the' veins in the 
Surgical Essays, published by Astley Cooper and himself in 1818-19. 
He introduced the use of mercury in non-specific iritis and in other 
forms of inflammation. Of all the English surgeons of this period, 
there are none whose writings are more interesting to-day than are those 
of Travers. 

In Edinburgh there was no surgeon of special note engaged in teach- 
ing after John Bell was excluded from the infirmary and gave up his 
school. No separate chair of surgery was established in the university 
until 1831, owing to the persistent opposition of the second Monro, who 
claimed to be professor of surgery as well as of anatomy. A chair of 
surgery was instituted in the College of Surgeons in 1804, which was 
maintained until the chair was created in the university in 1831, and 
this was filled by Dr. John Thomson (1765-1846), who became surgeon 
of the Royal Infirmary in 1800, and began to give clinical lectures 
therein on surgery in the private theatre in 1801, this being then the only 
separate course on this subject given in the city. In 1806 a chair of 
military surgery was instituted in the university, to which Dr. Thomson 
was appointed. His Lectures on Inflammation, etc. (Edinburgh, 1813) 
passed through several editions and translations, and his Report of Ob- 
servations made in the British Military Hospitals in Belgium after the 
Battle of Waterloo, etc. is of interest to army surgeons. 

A chair of clinical surgery was created in the university in 1803, 
which was filled by the appointment of James Russell, a surgeon of the 
Royal Infirmary, who published in 1794 A Practical Essay on a certain 
Disease of the Bones termed Necrosis (Edinburgh, 8vo), and in 1833, 
after his retirement, Observations on the Testicles. 

Sir George Ballingall (1780-1855) entered the army in 1806, and 
became professor of military surgery in the university in 1823. His 
principal work is his Outlines of the course of lectures oji Military Sur- 
gery, etc., published in 1833, which reached a fifth edition in 1855. 

Here also may be mentioned John Hennen (1779-1828), a distin- 
guished English military surgeon, a native of Ireland, who studied in 
Dublin and Edinburgh, and entered the army in 1800. His chief work 
is Observations on some important points in the practice of Military Sur- 
gery, etc. (Edinburgh, 1818), and subsequent editions, called Principles 
of Military Surgery (Edinburgh, 1820). 

In Glasgow at the beginning of the century the leading surgeon was 
John Burns (1775-1850), who was the first lecturer on anatomy who was 
unconnected with the university. His Principles of Surgery (2 vols. 



THE HISTORY AND LITEBATURE OF SURGERY. 95 

London, 1829-38) was dry and had no success, but his Principles on 
Midioifery reached a tenth edition. In 1815 he was appointed Regius 
professor of surgery in the University of Glasgow, and held this position 
until his death. 

Allan Burns (1781-1813) was a brother of John, whose demonstrator 
he became in the anatomical school. He first described the falciform 
process of the fascia lata in its relations to femoral hernia in a paper 
which he published in the Edinburgh Medical Journal in 1806. His 
Observations on the Surgical Anatomy of the Head and Neoh (Glasgow, 
1811) is a valuable surgical Avork, which contains, in addition to the 
anatomy, accounts of numerous cases of tumors in this region, a discus- 
sion on the treatment of aneurism, etc. He suggested the ligature of 
the innominate artery, and it was this suggestion which led to the first 
performance of the operation by Mott in 1821. 

Between 1825 and 1840 four surgeons in Edinburgh became distin- 
guished, and two of them were transferred to London to take high places 
there. These four were Lizars, Liston, Fergusson, and Syme. 

John Lizars (1783-1860) was a pupil of John Bell, and began to 
teach anatomy in a private school in 1815. In 1831 he became pro- 
fessor of surgery in the Royal College of Surgeons. He was the first 
in Scotland to ligate the innominate, and the second to perform ovariot- 
omy, an operation which became known mainly through his Observations 
on Extirpation of Diseased Ovaria (Edinburgh, 1825, fol.). His name 
is also connected with early operations for excision of the jaws. In 
1839 he ceased teaching and devoted himself to private practice. He 
was a skilled anatomist and a brilliant and daring operator. 

Robert Liston (1794-1847), a native of Scotland, was educated in 
Edinburgh and London, and began to teach anatomy in 1818. In 1823 
he gave up this teaching in favor of Syme and devoted himself entirely 
to surgery. He became surgeon of the North London Hospital and 
professor of clinical surgery in University College, London, in 1834, 
and rapidly achieved a great success. He was possessed of great per- 
sonal strength and was a brilliant operator, having the reputation of 
being the most dexterous surgeon of his time. His method of flap- 
amputation became very popular, and he made numerous contributions 
to the surgery of amputation, aneurism, lithotomy, and lithotrity. He 
would amputate the thigh with only the aid of one person to hold the 
limb and tie the ligatures, compressing the artery with his left hand, 
using no tourniquet, and doing all the cutting and sawing with the 
right. A large part of his skill and success was due to his knowledge 
of anatomy, which he kept up by dissections throughout his life. He 
excised the upper jaw for a formidable tumor in 1836, and the success in 
this instance brought to him a crowd of cases. His rashness is exempli- 
fied in the celebrated case in which he punctured an aneurism of the 
carotid, supposing it to be an abscess, although his house-surgeon had 
told him that the tumor pulsated. His principal publications were his 
Elements of Surgery, published in 1831, and his Practical Surgery, in 
1837, both of which works went through several editions. 

William Fergusson (1808-77), a native of Scotland, was educated at 
Edinburgh, being a pupil of Robert Knox. In 1831 he was elected 
surgeon to the Edinburgh Royal Dispensary, being at this time lectur- 



96 THE HISTORY AND LITEBATUBE OF SVRGEBY. 

ing on surgical anatomy in association with Knox, and was the first to 
ligate the subclavian in Scotland. In 1840 he accepted the professor- 
ship of surgery at King's College, London. In 1855 he was appointed 
surgeon extraordinary, and in 1867 Serjeant surgeon to the queen. For 
many years he was the leading surgical operator in London. He resigned 
his professorship of surgery in 1 870, but remained clinical professor of 
surgery and senior surgeon at King's College Hospital until his death. 
He was created a baronet in 1866. His special contributions to the art 
were largely in the line of what he called " conservative surgery," a 
term which he first applied in 1852 to the avoidance of amputation by 
means of resections and to the removal of no more than is absolutely 
necessary in cases of diseases of the bones. His name is especially asso- 
ciated with operations of hare-lip and cleft palate, with operations on the 
jaws, the excision of joints, and with lithotomy and lithotrity. His 
principal contribution to literature is his System of Practical Surgery 
(London, 1842; 5th ed. 1870). He also contributed many valuable 
papers to the periodicals. His lectures on the Progress of Anatomy and 
Surgery during the Present Century (1867) are extremely interesting to 
the student of the history of surgery. 

James Syme (1799-1870) was a pupil of Dr. Barclay, and when only 
nineteen years old was entrusted with the charge of his cousin Liston's 
anatomical rooms, in which he began to teach in 1822. In 1825 he 
began to teach surgery, but, having quarelled with Listen, he had no 
chance to obtain an appointment in the Royal Infirmary, and therefore 
started a private hospital. When he succeeded Russell in the clinical 
chair in the university, he became one of the surgeons of the infirmary 
in 1833, and after Liston went to London in 1834 the greater part of 
the operative surgery of Scotland fell into his hands. In 1831 he pub- 
lished his treatise on the Excision of Diseased Joints, which was the first 
systematic attempt to show that excision ought, in most cases, to super- 
sede amputation, and it had the greatest influence in bringing about this 
change in practice. The first edition of his Principles of Surgery was 
published in 1822 ; the fifth edition in 1863. This is an extremely con- 
cise work, and the fifth and last edition is smaller than the first. In 
1847 he published his Contributions to the Pathology and Practice of Sur- 
gery, in which he gives an account of the first eight cases of amputation 
at the ankle-joint by the method which is still known by his name. The 
date of his first case of this kind is September 8, 1842. In 1847 he 
accepted a call as surgeon to University College, London, on the death of 
Liston, but he did not find the place satisfactory, and four months later 
he returned to Edinburgh. He was a bold, cool, and skilful operator, 
but not a rash one. Among his most remarkable operations may be 
mentioned those for aneurism by incision of the tumor and ligations 
above and below, which operation he performed in cases of aneurism of 
the carotid, the axillary artery, and the iliac artery. 

In 1835 the greater part of the medical teaching in London was still 
given in private schools having no connection with hospitals, the oldest 
and best known being the Windmill Street and Aldersgate Street Schools. 
The Great Windmill Street School was established by William Hunter 
about 1746, and numbered among its teachers the two Hunters Baillie 
Cruikshank, Wilson, Mayo, Shaw, Brodie, Charles Bell, Carpue, and 



THE HISTORY AND LITERATURE OF SURGERY. 97 

Caesar Hawkins, but was finally destroyed by the establishment of the 
London University in the vicinity of the Middlesex Hospital in 1836. 
The Aldersgate School was also of old date, and numbered among its 
teachers Wardrop and Lawrence. 

The hospital schools of Guy's and St. Thomas's, which had been 
united in 1768, the surgical lectures being given at St. Thomas's and 
the medical at Guy's, were practically separated in 1825, and entirely 
so in 1836. 

After Liston and Fergusson came to London clinical hospital teach- 
ing increased rapidly in favor and importance ; the hospital schools 
began to flourish and the private schools to disappear. At this period, 
in addition to those already mentioned, the principal surgeons were 
Guthrie, Green, Lloyd, South, Morgan, Stanley, and Hawkins. 

George James Guthrie (1785-1856), an apprentice of a London sur- 
geon, was appointed hospital mate in the army, and sent to the York 
Hospital at Chelsea when he was only fifteen years old. He became 
assistant surgeon in 1801, accompanied his regiment to North America 
in 1806, and served during the War of the Peninsula in Spain, becom- 
ing surgeon of the forces in 1810, and commanding three divisions of 
cavalry at the battle of Albuera. He was placed on half pay in 1814, 
and went to the battle of Waterloo, where he performed an amputation 
at the hip-joint on a Frenchman, and tied both ends of the peroneal 
artery, being successful in each case. He became assistant surgeon to 
the Westminster Hospital in 1823, surgeon to the same hospital in 1827, 
and professor of anatomy at the Royal College of Surgeons in 1828. 
His treatise On gunshot wounds of the extremities requiring the differ- 
ent operations of amputations, etc., 1815, urging prompt amputation, 
marks an epoch in the history of military surgery ; the sixth edition, 
including additions relating to the Crimean War, was printed in 1855. 
In addition to this he published A treatise on the operations for the 
formation of an artificial pupil, etc. (1819), Lectures on the operative 
■surgery of the eye (1823; 3d ed. 1838), and On injuries of the head 
affecting the brain (4to, 1842 ; 2d ed. 1847). He also contributed many 
papers to medical journals. 

Joseph Henry Green (1791-1863), a nephew and pupil of Henry 
Cline, became surgeon to St. Thomas's Hospital in 1820 and professor of 
surgery in King's College in 1830. In 1837 he resigned his professor- 
ship, and in 1852 his position at St. Thomas's. His publications Avere 
chiefly short papers in medical journals. 

Eusebius Arthur Lloyd (1795-1862), a pupil of Abernethy, became 
assistant surgeon to St. Bartholomew's in 1824, and surgeon in 1847, 
from which position he retired in 1861. He gained the Jacksonian 
prize for 1818 by his essay on scrofula, enlarged and published in 1821. 

John Flint South (1797-1882), an apprentice of Henry Cline, was 
admitted as a member of the Royal College of Surgeons in 1819, after 
which he studied in Germany, and on his return became demonstrator at 
St. Thomas's Hospital, then lecturer on surgery, and ultimately surgeon 
to the hospital. He is best known by his translation of Chelius's Sys- 
tem of surgery, to which he added a large number of notes, greatly in- 
creasing the value of the work. He also collected materials for a His- 
tory of the craft of surgery in England, which was published in 1886, 

Vol. I.— 7 



98 THE HISTORY AND LITERATURE OF SURGERY. 

after his death, under the supervision of Mr. D'Arcy Power, and is a 
valuable book of reference. Through his efforts the remains of John 
Hunter were transferred to Westminster Abbey, and the inscription on 
the tablet is from his pen. 

John Morgan (1797-1847), a pupil of Astley Cooper, assisted Mr. 
Key as demonstrator of anatomy in a private school, was in 1821 
appointed assistant surgeon, and in 1824 surgeon, to Guy's Hospital, in 
the school of which he lectured on anatomy and surgery. In the latter 
part of his career he devoted himself to ophthalmology. He was an 
excellent operator, ligated the iliac artery several times, was one of the 
first to perform flap-amputations, and was the first to use metal sutures 
in wounds ; he was also one of the first to perform ovariotomy. His prin- 
cipal work was Lectures on diseases of the eye (1839). He also assisted 
Dr. Addison in An Essay on the operation of poisonous agents in the 
living body (1829). 

Edward Stanley (1791-1862) studied at St. Bartholomew's, to which 
he became assistant surgeon in 1816 and surgeon in 1838. He was 
twice president of the Royal College of Surgeons. His principal pubH- 
cation was A Treatise on the diseases of the bones (1849). 

Csesar H. Hawkins (1798-1884), prosector of anatomy in the school 
of Great Windmill Street for many years, became surgeop of St. 
George's Hospital in 1829, and retired in 1861. In 1861 he was presi- 
dent of the Royal College of Surgeons, and in 1862 Serjeant surgeon to 
the queen, succeeding Brodie, being the fourth of his family to hold 
this position. His works were collected and published in two volumes 
in 1874. 

Among the distinguished provincial surgeons of the century were 
George Freer of Birmingham, author of Observations on aneurism and 
some diseases of the arterial system (4to, 1807) ; Joseph Hodgson of 
Birmingham, best known by his treatise on Diseases of the arteries and 
veins (London, 1815; translated into French and German); John H. 
James (1789-1869) of Exeter, the author of the Jacksonian prize essay 
for 1818 on inflammation, and the second to ligate the abdominal aorta; 
John Green Crosse (1790-1850) of Norwich, author of the Jacksonian 
prize essay for 1825 on urinary calculus, and whose fine library on 
diseases of the urinary organs came into the possession of Professor 
S. D. Gross, and was destroyed by fire in Louisville ; John Gay 
^1791-1870) of Swindon, a pupil of Abernethy ; John Smith Soden 
(1780-1863) of Bath; George M. Jones (180?-1861) of Jersey, a bril- 
liant operator, who performed excision of the knee-joint without know- 
ing of Fergusson's operation a few weeks before, excised the hip and 
ankle-joints, extirpated the scapula, etc.; William Sands Cox (1802-76), 
one of the founders of the Birmingham School of Medicine in 1828, 
author of Memoir on amputation of the thigh at the hip-joint (1845) ; 
Thomas Pridgen Teale (1801-68), founder of the Leeds School of Med- 
icine, author of A practical treatise on abdominal hernia (1846; trans- 
lated into German 1848, and into Dutch 1849), and best known by 
his work. On amputation by a long and short rectanrjular flap (1858) ; 
Joseph Jordan (1786-1873) of Manchester, the first provincial lecturer 
on anatomy and surgery whose certificates were recognized by the Royal 
College of Surgeons (in 1821), founder of the Lock Hospital in 1819, 



THE HISTORY AND LITERATURE OF SURGERY. 99 

and surgeon of the Manchester Infirmary after 1835; George Southam 
(1815-70) of Manchester, founder of the Chatham Street School of 
Medicine in 1850, surgeon to the Royal Infirmary in 1855, and professor 
of surgery in Owens College on its foundation in 1872, author of Me- 
yional surgery (3 parts, 1882-86) ; and Joseph Sampson Gamgee (1828- 
86), the son of a veterinary surgeon, who studied at University Col- 
lege, London, and after graduation studied at Paris, Pavia, and Flor- 
ence. In 1857 Gamgee was appointed surgeon to the Queen's Hospital 
at Birmingham, which position he retained until 1881, becoming one of 
the most distinguished provincial surgeons of England. He was a bril- 
liant operator and a fluent speaker. He urged the dry, infrequent dress- 
ing of wounds. His principal publications are — On the advantages of 
the starched apparatus in the treatment of fractures and diseases of joints 
(1853), Researches in pathological anatomy and clinical surgery (1856), 
On the treatment of fractures of the limbs (1871/), and On the treatment 
of wounds (1878). 

The leading Dublin surgeons during the century were Colics, Cramp- 
ton, Carmichael, Porter, Cusack, Adams, Harrison, Bellingham, Smith, 
and Tufnell. 

Abraham Colics (1773-1843) graduated at Edinburgh in 1797, and in 
1804 became professor of surgery in Dublin, which position he held for 
thirty-two years, and for twenty years was the chief of the Irish sur- 
geons. His name remains connected with the form of fracture of the 
carpal extremity of the radius described by him in the Edinb. Med. and 
Surg. Journal (1814), and with the so-called "Colics' law" — /. e. that a 
mother infected with syphilis through the foetus acquires a certain degree 
of immunity and will not suifer by suckling the infant. In 1816 he 
first tied the subclavian within the scaleni. His principal surgical 
publications are a treatise on surgical anatomy (1811) and Lectures 
on the theory and practice of surgery (2 vols., 1844-45). 

Sir Philip Crampton (1777-1858), a native of Dublin, was appointed 
surgeon to the Meath Hospital when twenty-one years old, and was one 
of the founders of the first private school for anatomy and surgery in 
Dublin. He was a skilful operator and an eloquent lecturer, and con- 
tributed numerous papers to medical journals. 

Richard Carmichael (1779-1849), a native of Dublin, but of Scotch 
descent, passed his examination as assistant surgeon when seventeen 
years old, and in 1803 settled in Dublin and was appointed surgeon to 
St. George's Hospital. In 1826 he was one of the founders of the 
Richmond School of Medicine, giving lectures on surgery, and was very 
prominent in the various medical associations of his time. He be- 
queathed to the College of Surgeons in Ireland the sum of £3000, the 
interest of which was to be used in giving prizes every four years for the 
best essays on the state of the medical profession in Great Britain and 
Ireland, and these, known as the Carmichael prize essays, are valuable 
historical documents. His principal works relate to venereal diseases. 

William Henry Porter (1790-1861), a pupil of Mr. Crampton, was 
elected surgeon to the Meath Hospital in 1819, and in 1836 succeeded 
Colics as professor of surgery in the Royal College of Surgeons. He 
was a bold operator, an eloquent lecturer, and an excellent teacher. 
Besides a number of important papers in the journals, he published 



100 THE HISTORY AND LITERATURE OF SURGERY. 

Observations on the surgical pathology of the larynx and trachea (1826 ; 
2d ed. 1837), a classical work. 

James Williana Cusack(1787-]861), surgeon to Stevens's and Swift's 
hospitals, was in 1852 elected to the professorship of surgery in the 
University of Dublin, founded that year, and was three times president 
of the College of Surgeons. He was a bold and skilful operator, trained 
many pupils, and enjoyed the entire confidence of his professional brethren. 
He contributed some papers to periodicals, but wrote no special work. 

-Robert Adams (1791-1873), surgeon to the Jervis Street and the 
Richmond hospitals, was one of the founders of the Richmond (or, as it 
was afterward called, the Carmichael) School of Medicine, and in 1861 
was appointed Regius professor of surgery in the University of Dublin. 
His principal work was his Treatise on rheumatic gout, or chronic rheu- 
matic arthritis of all the joints (1857 ; 2d ed. 1873). 

Robert Harrison (1796-1858), a native of Cumberland, was appren- 
ticed to Colles in 1810, took the degree of M. B. in 1824, and was 
appointed professor of anatomy and surgery in the University of Dublin 
in 1837. His principal work was The surgical anatomy of the arteries 
(2 vols., 1824-26). 

O'Bryen Bellingham (1805-57) graduated at Edinburgh in 1830, and 
was elected surgeon to St. Vincent's Hospital in 1835. His name is 
especially connected with the treatment of aneurism by compression, a 
method which was systematized and made popular by Dublin surgeons, 
and with regard to which his little book. Observations on aneurysm, and 
its treatment by compression (1847), is still a valuable work. 

Robert William Smith (1807-73), a native of Dublin and an appren- 
tice of Richard Carmichael, was a teacher of surgery in the Richmond 
Hospital School, and in 1849 was appointed the first professor of surgery 
in the School of Physic of the University of Dublin, the chairs of 
anatomy and surgery having been united prior to that date. He was 
eminent as a teacher and as a skilled pathologist, was for thirty-five 
years secretary of the Dublin Pathological Society, and made numerous 
and valuable contributions to surgical literature. His principal work is 
A treatise on fractures in the vicinity af joints, and on certain forms of 
accidental and congenital dislocations (1847). 

Thomas JollifFe Tufnell (1819-75), a native of Chippenham, Wilts, 
studied in London under Brodie and Cffisar Hawkins, entered the army 
medical service in 1841, and after the Crimean War retired from active 
service and settled in Dublin. He was surgeon to the City of Dublin 
Hospital and professor of military surgery in the school of the College 
of Surgeons. His principal works were — Practical remarks on the treat- 
ment of aneurism by compression (1851) and The successful treatment of 
internal aneurism (1864; 2d ed. 1875). 

In addition to those already mentioned, and excluding those yet 
living,_ the following have been the prominent London surgeons since 
the middle of the century : 

James Luke (1798-1881) studied at the London Hospital, where he 
became lecturer on anatomy in 1823, lecturer on surgery in 'l 825 and 
surgeon to the hospital in 1833, which position he resigned in 1861. 
His name is specially connected with a simplified method of operation 
for femoral hernia. 



THE HISTORY AND LITERATURE OF SURGERY. 101 

Frederic Carpenter Skey (1798-1872), a pupil of Abernethy, was 
for ten years lecturer on surgery in the Aldersgate School, and in 1843 
became professor of anatomy at St. Bartholomew's Hospital, to which 
he had been elected assistant surgeon in 1827, and where he became sur- 
geon in 1854, retiring in 1864. Plis principal work was his treatise on 
Operative surgery (1850 ; 2d ed. 1858). 

John Hilton (1804-78) studied at Guy's Hospital, in the medical 
school of which he was appointed demonstrator of anatomy in 1828, 
and held this position for fourteen years, being reputed to be the best 
anatomist in London. In 1845 he was appointed assistant surgeon, and 
in 1849 surgeon, at Guy's. He is best known by his book on Best and 
pain (1863 ; 2d. ed. 1877), one of the most valuable contributions of 
the century to surgical literature. 

Edward Cock (1805-92), nephew and pupil of Astley Cooper, was 
appointed demonstrator of anatomy in Guy's Hospital medical school 
on its foundation in 1825, assistant surgeon to the hospital in 1838, and 
surgeon in 1848, retiring in 1871. He is best known by his papers on 
puncture of the bladder through the rectum (1852) and on a method of 
opening the urethra in cases of impermeable stricture (1866). 

William Coulson (1802-77), a pupil of Tyrrell, studied in Berlin for 
two years, and on his return was associated with Tyrrell, Jones, Quain, 
Lawrence, and Wardrop in the medical school in Aldersgate street, in 
which he taught anatomy. At the same time he was on the editorial 
staff of The Lancet. In 1851 he was elected surgeon to St. Mary's Hos- 
pital. His principal works relate to diseases of the urinary organs. 

Henry Hancock (1809-80) studied under Guthrie, became demon- 
strator of anatomy at the Westminster Hospital School in 1835, and in 
1839 assistant surgeon at Charing Cross Hospital, where he succeeded 
to the lectureship of surgery on the death of Mr. Howship in 1841. 
His principal work was On the operative surgery of the foot and ankle- 
joint (1873). 

Thomas Blizard (1811-88), a native of London and nephew of Sir 
William Blizard, became assistant surgeon to the London Hospital in 
1833 and surgeon in 1849, from which position he retired in 1869. His 
principal publications were — A Treatise on tetanus (Jacksonian prize 
essay, 1836), Praetieal treatise on the diseases of the testicle, spermatic 
cord, etc. (London, 1843 ; 4th ed. 1878), and Observations on the diseases 
of the rectum (London, 1851 ; 4th ed. 1876). He contributed a number 
of very valuable papers to the Medico-ohirurgical Transactions, including 
his " Improved observations on acute ulcerations of the duodenum in 
cases of burn" (1842). 

Campbell de Morgan (1811-76), a younger brother of the mathema- 
tician, Augustus de Morgan, and a pupil of Sir Charles Bell, studied at 
University College, and in 1842 was elected assistant surgeon to the Mid- 
dlesex Hospital, becoming full surgeon in 1848. In 1866-67 he became 
joint lecturer on surgery with Mr. Shaw. He contributed to Holmes's 
System, of surgery and some papers to periodicals, and published The 
origin of cancer considered with reference to the treatment of the disease 
(1872). 

John Gaiy (1813-85) studied in London, and in 1836 became surgeon 
to the newly-established Royal Free Hospital. In 1856 he was surgeon 



102 THE HISTORY AND LITERATURE OF SURGERY. 

to the Great Northern Hospital. His principal works are — On femoral 
rupture (1848) and On varicose veins (1868). He must not be con- 
founded with John Gay (1791-1870), a distinguished surgeon at Swindon 
and a pupil of Abernethy, who graduated in 1811, or with his son of the 
same name, who died at Swindon in 1869. 

Eobert Druitt (1814-83) was not connected with any hospital and did 
not practise surgery, but his Vade Meewni, the first edition of which ap- 
peared in 1838 and contained the teachings of Green and of Joseph 
Henry, met with great favor, reaching its eleventh edition in 1878 and 
a sale of forty thousand copies. 

Richard Holmes Coote (1817-72), a pupil of Sir William Lawrence, 
became demonstrator of anatomy at St. Bartholomew's in 1846, assistant 
surgeon to the hospital in 1852, and surgeon and lecturer on surgery in 
1863. He contributed many papers to journals and transactions, and is 
best known by his treatise On joint diseases, published in 1867. 

John Marshall (1818-91), a student and assistant of Liston, became 
surgeon of University College Hospital and professor of surgery, in 
which position he gave special attention to physiology and pathology 
and to the views of Virchow, Cohnheim, and other German authorities. 
During the latter part of his life he was president of the General Medical 
Council. His principal published work was his Outlines of physiology 
(2 vols., 1867). 

Alfred Poland (1822-72), a pupil of Mr. Aston Key, became dem- 
onstrator of anatomy at Guy's Hospital in 1845, assistant surgeon of 
the hospital in 1849, and full surgeon in 1861. His Essay on gunshot 
wounds and their treatment received the Jacksonian prize at the College 
of Surgeons, and his paper. The injuries and wounds of the abdomen, 
gained for him the Fothergillian medal of the Medical Society of Lon- 
don. He contributed many papers to Guy's Hospital Reports and also 
to the weekly medical journals, but wrote no important separate work. 

John Cooper Forster (1823-86), the son of a medical man, studied at 
Guy's, where in 1850 he was appointed demonstrator of anatomy, in 
1855 assistant surgeon, and in 1870 surgeon, which latter position he 
resigned in 1880. He performed the first gastrostomy in England in 
1858. His only published separate work was on The surgical diseases 
of children (1860). 

George William Callender (1830-79) studied at St. Bartholomew's, 
where he became assistant surgeon in 1861, surgeon in 1871, and lec- 
turer on surgery in 1873. He contributed largely to »SV. Bartholomew's 
Hospital Reports, of which he was surgical editor from 1865 to 1873 
and also furnished many papers and notes of clinical lectures to journals 
and transactions. The Transactions of the Royal Society for 1869 con- 
tain an important paper by him on " The formation and growth of the 
bones of the human face." He was one of the first to carry out in detail 
asepsis in surgery, as contradistinguished from antisepsis. His only 
separate work was Anatomy of the parts concerned in femoral rupture 
(1863). ^ 

Peter Charles Price (1832-64), the son of a physician, studied at 
King's College, and became assistant to Mr. Fergusson in 1854. He was 
appointed assistant surgeon to King's College Hospital in 1861. He 
paid special attention to the pathology and surgery of the joints and more 



THE HISTORY AND LITERATURE OF SURGERY. 103 

especially to the diseases of the knee and tlieir treatment by excision. 
His principal work is A Description of the diseased ccniditions of the knee- 
joint which require amputation of the limb, and those conditions which are 
fai'orable to excision of the joint, etc., published after his death in 1865. 

Charles Frederick Maunder (1832-79) studied in Bristol, London, 
Edinburgh, and Paris, served in tlie army during the Crimean War, and 
was appointed assistant surgeon to the London Hospital in 1860, and 
surgeon in 1869. He was a bold and skilful operator, and his text-book 
on operative surgery (1860; 2d ed. 1873) was an excellent manual. 

William Frederick Teevan (1833-87) was educated at University 
College, and was elected assistant surgeon of the West London Hos- 
pital for Urinary Diseases in 1866, after which he devoted himself 
more especially to the surgery of the genito-urinary organs. He is best 
known by his work, Inquiry into the causation, diagnosis, and treatment 
of fractures of the internal table of the skull (1864), which is a classical 
work of reference on this subject. 

Marcus Beck (1 843-93) studied at Glasgow under Mr. Joseph Lister, 
his cousin, and at University College, London, and in 1873 was appointed 
assistant surgeon to University College Hospital, becoming surgeon in 
1885 and lecturer on surgery in the same year. He was one of the first 
to introduce antiseptic methods in surgery in London, and, though not a 
voluminous writer, made some valuable contributions to surgical litera- 
ture, including a paper on " Consecutive nephritis," or surgical kidney, 
in Reynolds's Sydem of medicine, and a part of the report on pyaemia 
and septicaemia in the Transactions of the Pathological Society for 1879. 

Frederick LeGros Clark (1811-92), an apprentice of Travers, stud- 
ied at St. Thomas's Hospital, beginning in 1827, and was appointed 
assistant demonstrator of anatomy in 1830. In 1839 he became lec- 
turer on anatomy and physiology, in 1843 assistant surgeon to the hos- 
pital, and in 1853 full surgeon, which office he retained for twenty years. 
When Mr. South resigned the chair of surgery Mr. Clark succeeded him, 
and retained the office until he retired from the hospital in 1873. His 
principal work was his Lectures on the principles of surgiccd diagnosis : 
especially in relation to shock and visceral lesions (London, 1870; 2d 
ed. 1872). A number of his papers in journals and addresses were 
collected and printed under the title of Pctpers on surgery, pathology, 
and allied subjects (8vo, London, 1889). 

The two greatest advances in surgery in the nineteenth century are 
the introduction of anaesthetics, which was due to American surgeons, 
and will be referred to hereafter, and the introduction of systematic and 
scientific antisepsis and asepsis in the treatment of wounds and the per- 
formance of surgical operations, which is due to an English surgeon, 
Sir Joseph Lister, who brought it into notice in 1867-68. Antiseptics 
of various kinds had been proposed and used by others prior to this 
date. Kiichenmeister of Dresden had reported good results from the 
use of carbolic acid in 1860 ; Lemaire's work on carbolic acid appeared 
in 1863; Campbell de Morgan used chloride of zinc in 1866; but it 
was Mr. Lister who established the method on the basis of Pasteur's 
experiments showing that putrefaction is due to the action of micro- 
organisms, and who systematically sought for, and found, means to pre- 
vent the access of these micro-organisms to wounds or to destroy their 



104 THE HISTORY AND LITERATURE OF SURGERY. 

vitiility if they had already gained admission, and to do this with the 
least possible injury to the living tissues. The actual cautery and the 
boiling oil of the surgeons of the fifteenth and prior centuries were 
antiseptic, no doubt, as were also some of the multifarious wound-dress- 
ings in use since the days of Hippocrates ; but antiseptic surgery^ began 
with Mr. Lister, and its progress has been largely due to the scientific 
manner in which he developed and expounded it. With the introduc- 
tion of Koch's method of cultures on solid or semi-solid media, which 
is tlie foundation of the new bacteriology, has come a knowledge of the 
mode of development and of the results of the growth of some of these 
organisms which has already revolutionized operative surgery, and 
made obsolete and comparatively useless a vast amount of surgical 
literature and statistics. An illustration of this is given in a compari- 
son of the results obtained by Liston in 1844 with those obtained in the 
University College Hospital forty years later, contained in an address on 
surgery by John Marshall in the British Medical Journal (August 8, 
1885, p. 235). He concludes that "injuries not involving a breach of 
the surface of the body, simple inflammations consecutive to these, or so- 
called idiopathic local inflammations which come under the care of the 
surgeon, such as sprains, simple dislocations, synovitis, orchitis, and 
other cases, were not less satisfactorily treated in 1844-45 than in 1883, 
and the progress of the patients toward recovery was quite as rapid, but 
that in cases of wounds and operations the difference in favor of the 
latter period is very striking." 

After the abolition of the medical faculties and societies in France by 
the decrees of 1792 and 1793 the evil results of want of means for giv- 
ing proper medical instruction soon became evident from the fact that 
properly-qualified medical officers could not be found to supply the 
places of those who died in the service of the armies of the Kepublic. 
By direction of the National Convention a report was prepared by the 
celebrated chemist, Fourcroy, on the best plan of organizing medical 
schools to meet this want, and in accordance with this report a law was 
passed in 1794 establishing medical schools at Paris, Montpellier, and 
Strasburg. The method taken to secure students was peculiar and eifec- 
tual. From each district in France a young man between seventeen 
and twenty-six years of age, whose name had not been drawn in the first 
conscription, was selected by the governmental authorities and forwarded 
at the expense of the State to one of these schools, three hundred being 
assigned to Paris, one hundred and fifty to Montpellier, and one hundred 
to Strasburg. Three years was the period of instr.uction allowed, and as 
soon as they were considered qualified they were sent to join the troops. 
These were really military medical schools analogous to that established 
at Berlin. They did not confer the doctor's degree, the object being 
simply to manufacture medical officers as soon as possible. 

After several changes the Paris school was definitely organized in 
1804, and became a medical society as well as a teaching body, the 
object of the government being to obtain not only a medical faculty, 
but a scientific body which should be capable of giving advice to the 
government. The society part of this arrangement was dissolved in 
1821 by the formation of the Academy of Medicine. 

In 1806 the Imperial University was created, and in 1808 the med- 



THE HISTORY AND LITERATURE OF SURGERY. 105 

ical school became its faculty of medicine. In 1822, owing to political 
troubles, the Faculty of Medicine was suppressed, but it was re-estab- 
lished in 1823 with a change in a number of the professors, A. Dubois 
and Pelletan losing their chairs. 

In 1830 the Faculty of Medicine was again reorganized, the acts 
of 1822 and 1823 being abolished and the old professors being again 
placed in their chairs, while at the same time the concours was again 
established as a means of tilling the professorships. Jules Rochard, in 
his Histoire de la ohlrurgie frangaise au xix" si^cle (Paris, 1875), gives 
the most complete and satisfactory account of French surgery of the 
century, and his division of it into four periods will be followed in this 
sketch. 

At the beginning of the century the leading surgeons in Paris were 
Sabatier, Deschamps, Lassus, Boyer, Dubois, Pelletan, and Lallement. 
Sabatier and Deschamps have already been referred to in speaking of 
French surgeons in the latter part of the eighteenth century. 

Pierre Lassus (1741-1807), professor of surgery in the iScole de 
Sante and consulting surgeon of Napoleon I., was a learned surgeon who 
was the author of a good history of anatomy, of a manual of operative 
surgery (2 vols., Paris, 1794), and of Pathologie chirurgicale (2 vols., 
Paris, 1805-06). 

Alexis Boyer (1757-1833) was a pupil of Desault and surgeon of the 
Charity, a modest, quiet, studious, hard-working man, without much 
originality or brilliancy either in his clinical work or his lectures and 
writings, but a careful compiler and a thoroughly reliable teacher. His 
Traite des maladies chirv,rgioales (11 vols., 1814-26) is a practical sys- 
tem of surgery, the most complete of its kind then in existence, and for 
many years it remained the highest authority in this branch of medical 
literature. His chief contributions to practical surgery were his descrip- 
tions of the painful crepitation of tendons, of translucency of the tumor 
as diagnostic in hydrocele, of bleeding fungous tumors, and of the com- 
plications of fissure of the anus. His system is characterized by Mal- 
gaigne as a summary of the works and opinions of the French Academy 
of Surgery, which is no doubt correct. It is a r6sumd of French sur- 
gery which he gives, and he has little or nothing to say of the surgery 
of Germany, of England, or of America. 

Antoine Dubois (1756-1837), a pupil of Desault, professor of anat- 
omy in the lllcole de Sant6, was a skilful surgeon and a good clinical 
teacher, but wrote nothing of importance. 

Philippe Jean Pelletan (1747-1829), a pupil of Louis and of Sabatier, 
succeeded Desault as chief surgeon at the H6te] Dieu, became professor 
of clinical surgery at the founding of the Medical Faculty of Paris, and 
consulting surgeon to the emperor. In 1815 he was professor of opera- 
tive surgery, and retired from practice in 1823. He was an eloquent 
lecturer, but made no valuable contributions to the art. His Clinique 
Ghirurgieale (3 vols.) was published in 1810-11. 

Andr6 Marie Lallement (1 750-1830), a pupil of Desault, was surgeon 
to the Salp^trifere and professor of surgery in the Medical Faculty. He 
wrote only a few papers for periodicals. 

To these should be added the names of Larrey, Percy, Dufouart, and 
Saucerotte. 



106 THE HISTORY AND LITERATURE OF SURGERY. 

Dominique Jean Larrey (1766-1842), the most distinguished military- 
surgeon at the end of the last and the beginning of the present century, 
served in the Napoleonic campaigns, and was professor in the military 
school founded in 1796 at Val-de-Grace. His chief writings are his 
Mknoires de medeolne militaire et campagnes (4 vols., Paris, 1812-17) 
and his Recueil de memoires de chiruryie (Paris, 1821). 

Pierre rran9ois Percy (1754-1825) was professor in the military 
medical school in 1820. At his suggestion a battalion of litter-bearers, 
or a hospital corps, was created in the Italian war. 

To the second period (1814^35) belong Dupuytren, Kicherand, Koux, 
Marjolin, Lisfranc, Sanson, and Jules Cloquet. 

Guillaume Dupuytren (1778-1835) at the age of eighteen obtained by 
concours a position as prosector in the Academy, in 1801 became chief 
of the department, in 1808 obtained a place on the surgical staff of the 
Hotel Dieu, in 1812 was appointed to the chair of operative surgery, and 
in 1815 became surgeon-in-chief to the H6tel Dieu. For the next fifteen 
years he was the most distinguished surgeon in France — and, for that 
matter, in the world, as the fame of his clinical teaching drew crowds of 
students from all countries. His studies in pathological anatomy and in 
experimental physiology contributed greatly to his success, which turned 
largely on his unequalled powers of diagnosis. 

He was not a student of books, and wrote but little, and that little is 
not remarkable. He made no great discoveries, his chief contributions to 
the art being his method of treating artificial anus by means of his com- 
pressing enterotome, his excisions of the jaws, and the subcutaneous 
section of the sterno-mastoid. He was a cold, reserved, unscrupulous, 
and ambitious man, with contemptuous and offensive manners, who can 
hardly be said to have had any personal friends ; but he was an incessant 
worker, thoroughly self-reliant, a bold operator, and unsurpassed as a clin- 
ical teacher in the precision, method, and clearness with which he stated 
all the salient points of the case on hand. His clinical lectures were 
noted and published by Biierre de Boismont and Buet in 1 832—34 in 4 
volumes ; a second edition, in 6 volumes, appeared in 1839. Those por- 
tions of these lectures which relate to injuries and diseases of the bones 
were translated by F. Le Gros Clark and published by the Sydenham 
Society in 1847 ; and other selections, under the title of On lesions of the 
vascular system, diseases of the rectum, etc., by the same translator, form a 
volume of the Sydenham Society's publications issued in 1854. 

Balthasar Anthelme Richerand (1779-1840) published his Nosographie 
chirurgicale (1805-06, 3 vols. ; 5th ed. in 1821, 4 vols.). He was ap- 
pointed professor of surgical pathology in the faculty by Napoleon in 
1807. He was more successful as a writer than he was as an operator 
or teacher, but he had nothing of the impartial spirit of the true critic, 
and the man whom he praised one year he would denounce the next. 
He made no special contributions to surgery with the exception of a case 
of resection of the fifth and sixth ribs on the left side, being the first 
instance in which such an operation had been performed to this extent. 

Philibert Joseph Roux (1780-1854) was a student and warm personal 
friend of Bichat, whom he succeeded as a teacher. He became surgeon 
at the Charitd in 1810, professor of surgery in the faculty in 1820, and 
succeeded Dupuytren at the Hotel Dieu in 1835. He first became cele- 



THE HISTORY AND LITERATURE OF SURGERY. 107 

brated by the publication, in 1815, of his Relation d'un voyage fait & 
Londres en I8I4. ; ou parallile de la chirurgie angloise aveo la ehirurgie 
frayigoise — a book which had considerable influence in diifusing in each 
country a knowledge of what had been done in the other, in spite of the 
crude and superficial views on many points which it presented. His 
most important contributions to the art were in plastic surgery, partic- 
ularly in staphylorrhaphy, which he first performed in 1819, and in 
suture of the ruptured perineum, which he first performed in 1832. He 
gave the first distinct course of lectures on surgical anatomy in 1812. 
His most important literary work was his Quarante annSes de pratique 
ohirurgicale, of which but two volumes were published, the first, relating 
to plastic surgery, appearing in 1854, and the second, on diseases of the 
arteries, in 1855. 

Jean Nicolas Marjolin (1780-1850) was prosector of anatomy in 
1806, and in 1816 became second surgeon of the Hdtel Dieu, but soon 
retired to avoid unpleasant association with Dupuytren. In 1819 he 
became professor of surgical pathology. He was a good surgeon and 
extremely popular as a teacher, but was not distinguished as an operator. 
His name remains connected with the form of malignant degeneration of 
chronic ulcer of the leg known as the " warty ulcer of Marjolin." 

Jacques Lisfranc (1790-1847) studied at Lyons and Paris and gradu- 
ated in 1813, after which he served for a short time in the army and 
then settled in Paris. In 1825 he became second surgeon at La Piti6, 
and a short time afterward, on the death of BSclard, he became the 
chief surgeon at this hospital. He sought to reduce operative surgery 
to mathematical rules, and his name is connected with methods of par- 
tial amputation of the foot, of amputation at the wrist, the shoulder-joint, 
and the hip, and with methods of resection of the head of the humerus, 
for removal of the lower jaw, for excision of the rectum, and for ampu- 
tation of the neck of the uterus. He was an excellent operator and 
clinical teacher, but envious of the greater success of some of his contem- 
poraries, particularly Dupuytren and Velpeau, and died dissatisfied with 
himself and with every one around him. His principal publications are — 
Clinique chirurgicale de Vhopital de la Pitii (3 vols. 8vo, Paris, 1841-43) 
and Precis de mSdecine operatoire (3 vols. 8vo, Paris, 1845-48). 

Louis Joseph Sanson (1790-1841) was a pupil and friend of Dupuy- 
tren. After serving in the army from 1812 to 1815, he returned to Paris, 
and in 1825 became the second surgeon of the Hotel Dieu. In 1836 he 
succeeded Dupuytren as professor of clinical surgery, winning the place 
by concours. The first forty years of his life were a continued struggle 
with poverty, and his subordination to Dupuytren prevented him from 
obtaining the reputation to which his skill as a diagnostician and operator 
entitled him. His principal work was the Nouveaux M&nents de patho- 
logie mklico-ehirurgicah, par Roche et Sanson (4 vols., 1824 ; 3d ed. 
1833), of which he wrote all the surgical part. 

Jules Germain Cloquet (1790-1883) came to Paris in 1810 and be- 
came preparer for the museum of the School of Medicine. He published 
a valuable series of anatomical observations on hernia in 1817, and a 
magnificent work on human anatomy, containing a large number of plates, 
which is still classic; in 1831 he became professor of surgical pathology, 
and succeeded Dubois in the chair of clinical surgery in 1833, which 



108 THE HISTORY AND LITERATURE OF SURGERY. 

position he retained until 1850. He contributed a large number of 
papers on anatomical and surgical subjects to the journals, and devised 
a number of new instruments. 

Joseph Souberbielle (1754-1846) studied at Paris under Desault and 
entered the army. He took his degree in 1813, after which he remained 
in Paris, devoting himself chiefly to lithotomy, and especially to the 
suprapubic method. He was a relative of Frfire C6me and of his 
nephew Baseilhac, and inherited their instruments and reputation. He 
is said to have performed the suprapubic operation over twelve hundred 
times. 

To this period belongs the introduction of lithotrity, with which are 
especially connected the names of Civiale, Leroy (d'£tiolles), and Heur- 
teloup. 

Jean Civiale (1792-1867) studied at Paris, graduating in 1820, and 
made a specialty of the diseases of the urinary organs, and especially of 
lithotrity, which he successfully performed on a living human subject in 
January, 1824. In 1828 a special section for those afflicted with calculus 
was set apart for him in the Hospital ISTecker, and his practice became 
enormous. He had much mechanical ingenuity and dexterity, but he 
was neither a speaker nor a writer, and the greater part of the numerous 
publications which appeared under his name were really written by 
Jourdan, Boisseau, B^gin, and others. In his first book, Nouvellen con- 
sidSrations sur la rHention d'urine, etc. (1823, p. 115), he referred to a 
report of Pouteau that " haricots blancs " had passed from the stomach 
into the urinary bladder, etc., and said : " Si les faits rapport^s sont exacts, 
ces corps suivent-ils le torrent de la circulation?" Some kind friend 
pointed out the blunder to him before the edition Avas put on the market, 
and he cancelled the greater part, but a few had been sent out as pres- 
entation copies, and these are now regarded as curiosities in medical 
literature. 

Jean Jacques Joseph Leroy (d'fitioUes) (1798-1860) studied at Paris, 
graduating in 1824, prior to which he had devised a three-pronged 
instrument for seizing and perforating a stone in the bladder, and his 
whole life was mainly devoted to this branch of surgery and to bitter 
contests as to priority of invention. He was not, however, a pure 
specialist, and was a much more scientific man than Civiale. The list 
of his publications is a long one, but they are comparativelv brief 
papers. 

Charles Louis Stanislaus Heurteloup (1793-1864), son of Baron 
Nicolas Heurteloup, a distinguished French army surgeon, studied in 
Paris, graduating in 1823, and almost immediately turned his attention 
to the subject of lithotripsy and to criticism of the work of Civiale and 
Leroy (d'Etiolles). He greatly improved the instruments used in lith- 
otripsy, and is said to have spent one hundred and fifty thousand francs 
in perfecting his inventions. From 1828 to 1832 he was in London, 
and published there his Principles of Lithotrity (1831). 

To this period also belong Delpech and Lallemand of Montpellier. 

Jacques Mathieu Delpech (1777-1832), a native of Toulouse, gradu- 
ated at Montpellier in 1801, after which he studied in Paris. In 1812 
he obtained, by concours, the chair of surgery at Montpellier, and soon 
became celebrated as an operator and as a clinical teacher. In the heio-ht 



THE HISTORY AND LITERATURE OF SURGERY. 109 

of his fame- he was assassinated by a patient whom he had treated for 
some disease of the genitals. His principal contributions to surgery 
relate to hospital gangrene and to orthopsedia. He first pointed out that 
tubercular disease of the vertebrae was the frequent origin of Pott's dis- 
ease of the spine, insisted on the importance of the fibrous tissues in con- 
nection with deformities, and in 1816 performed subcutaneous section of 
the tendo Achillis with the avowed intention of thus excluding the air 
and obtaining union by first intention. The successor of Delpech in 
the chair of clinical surgery was Michel Serre (1799-1849), who gradu- 
ated at Montpellier in 1825, and who published his Traitv de la rhmion 
immediate, etc., in 1830, and his Traits sur I' art de restaurer les diffbrm- 
it6s de la face, etc., in 1842. 

Claude Fran9ois Lallemand (1790-1853), a native of Metz, studied 
at the Military Medical School of that place, and at the age of thirteen 
entered the army medical service. In 1811 he went to Paris and became 
an assistant to Dupuytren ; in 1819 he was appointed professor of clinical 
surgery at Montpellier ; and after the death of Delpech he was the chief 
surgeon in the south of France. In 1823 he lost his place for ten months 
through clerical intrigues, but was replaced by the Council of Public 
Instruction. He is best known as the author of Des pertes sSminales 
involontaires (3 vols., 1836-42), of which several English translations 
were published. He devised the method of autoplasty by bending with- 
out twisting the flap, and the method of treating erectile tumors by the 
insertion of needles. 

In the third period (1835-47) come Grerdy, Velpeau, Blandin, A. 
B^rard, Laugier, Jobert, Amussat, and Vidal. 

Pierre Nicolas Gerdy (1797-1856) studied in Paris under the most 
adverse circumstances of poverty and sickness, and in 1828 became 
second surgeon to La Piti6, where he was under the orders of Lisfranc, 
who gave him very few opportunities. In 1831 the surgeons of the 
hospitals were placed on an equal footing, the position of surgeon-in- 
chief being abolished. In 1833, as the result of an intrigue of Dupuy- 
tren to suppress Velpeau, Gerdy became professor of the principles of 
surgery in the faculty, and in 1839 was appointed surgeon to La Charitd, 
taking the place of Guerbois. The list of Gerdy 's works is a long one, 
but he was a physiologist rather than a surgeon, and his most important 
surgical publication was his Traite des bandages et des pansemenfs (2 
vols., 1837-39). 

Alfred Armand Louis Marie Velpeau (1795-1867), the son of a 
blacksmith, whose trade he learned, studied at Tours, where he received 
the diploma of qfficier de santi, and in 1820 came to Paris, and soon 
became assistant preparer for Cloquet. He graduated in 1823, and pub- 
lished his Traits d'anatomie ohirurgioale, the first complete and syste- 
matic work in which the details of regional anatomy Avere throughout 
considered with reference to their surgical relations. In 1828 he became 
surgeon to the Hospital St. Antoine, and in 1830 to La Piti6, where he 
remained until 1834, when he was elected to the chair of clinical sur- 
gery in the faculty left vacant by the death of Boyer. In 1832 he pub- 
lished his Nouveaux iliments de m&deaine operatoire (3 vols, and atlas), 
the largest and most complete work on this subject which had yet 
appeared. The English translation of this by Townsend, with notes 



110 THE HISTORY AND LITEBATUBE OF SURGERY. 

of Valentine Mott (New York, 1847), and especially the latest edition, 
with additions by G. C. Blackman (New York, 1856, 3 vols, and atlas), 
is a great storehouse of historical data relating to the principal opera- 
tions of surgery up to that date. In 1854 he published his TraiU des 
maladies du sein, a large book, characterized by Trelat as the most orig- 
inal, personal, and probably the most durable of his works, and which 
must not be confounded with his Petit traits des maladies du sein, pub- 
lished in 1838 as a reprint of his article in the Dictionnaire de midecine, 
and which was translated into English by Parkman in 1840. He made 
no great discoveries or improvements, yet he contributed greatly to the 
progress of surgery between 1825 and 1855, and especially in surgical 
anatomy, the pathology of pysemia, the diagnosis of tumors, and the 
diseases of the breast. A man of strong common sense, an indefatigable 
worker, a conscientious and conservative critic, an excellent teacher and 
operator, his lessons were followed by crowds of pupils, including many 
who became distinguished surgeons in other countries as well as in 
France. 

Philipp Frederic Blandin (1798-1849) graduated at Paris in 1824, 
in 1828 became a surgeon to the Hospital Beaujon under Marjolin, 
and in 1841 succeeded Richerand in the chair of operative surgery. 
He also became surgeon to the H6tel Dieu. Blandin was not a great 
surgeon nor a great teacher, and there is little in his writings which is 
of interest at the present day, but he was a sensible, practical, honest 
man who did good work in his time. 

Auguste B^rard (1802-46) studied at Paris, graduating in 1829, 
became a surgeon of the Central Bureau by concours in 1831, and, sub- 
sequently, surgeon to the hospitals St. Antoine, Salp§tri6re, Necker, and 
La Piti6, and in 1842 succeeded Sanson as professor of clinical surgery 
in the faculty. The student part of his life was one of great poverty, 
shared by his brother, P. Bfirard, who devoted himself to physiology. 
A. B6rard wrote some excellent concours theses, many articles in the 
Dictionnaire de medeciite, and began, with Denonvilliers, a Compendium 
de ohiruirjie pratique, of which only a portion was issued at his death. 
His contributions to surgery relate to the treatment of fractures, con- 
tinuous irrigation of wounds, erectile tumors and varices, staphylor- 
rhaphy, etc. He was a skilful operator and an excellent teacher. 

Stanislaus Laugier (1799-1872), a pupil of Dupuytren, graduated at 
Paris in 1828, became surgeon to the Hospital Necker in 1832, to the 
Hospital Beaujon in 1836, professor of clinical surgery in the faculty in 
1848, and surgeon to the H6tel Dieu in 1854, succeeding Roux. He 
first called attention to the discharge of serous fluid from the ear in 
certain fractures of the skull, and was the first to propose suture of 
divided nerves. He was a prudent, quiet, conservative surgeon and a 
good teacher, but he wrote little and his name is now almost forgotten. 

Antoine Joseph Jobert (1799-1867) studied at Paris, graduated in 

1828, was appointed a surgeon of the Central Bureau by concours in 

1829, and surgeon to the Hospital St. Louis in 1831. In 1853 he 
became surgeon to the Hdtel Dieu, and in 1854 succeeded Roux as pro- 
fessor in the faculty. His childhood and student-life were spent in 
great poverty, at times in actual destitution ; his subsequent life was a 
very unhappy one, in spite of the honors and wealth to which he attained ; 



THE HISTORY AND LITERATURE OP SURGERY. Ill 

he became gloomy and eccentric, and ended his days in an asylum for 
the insane. Lacking in preliminary education and in oratorical gifts, 
his success was due to the novelty and importance of his contributions 
to plastic surgery and to the surgery of the female organs of generation. 
He was a better writer than speaker, and wrote much ; his llimoire sur 
les plaies du canal intestinal, published in 1826, before his graduation, 
was based upon the experimental method of Hunter, and demonstrated 
the importance of producing union between the serous surfaces. His 
most important works were — Traite de cliirurgle jilastique (2 vols, and 
atlas, 1849), Traite des fistules vesico-utc'rines, etc. (1852), and De la 
reunion en chirurgie (1864). 

Jean Zulema Amussat (1796-1856), the son of a country physician, 
entered the army medical service in 1814, after which he studied at 
Paris, graduating in 1826. He did not become a professor in the 
faculty or surgeon to a great hospital, but he commenced private teach- 
ing even before he graduated, and he communicated most of his discov- 
eries to the Academy of Medicine, which granted him prizes for his 
contributions on lithotrity, on the torsion of arteries, on the entrance of 
air into the veins, on lumbar colotomy, etc. He wrote much, but his 
papers were never collected. 

Auguste Thfiodor Vidal (de Cassis) (1803-56) studied at Marseilles 
and Paris, graduating in 1828, soon after which he became connected 
with the newly-founded Gazette des hdpita.ux. He never became a pro- 
fessor or connected with a great surgical clinic, and, being a sarcastic 
journalist and rather bitter critic, he made few friends. His reputation 
as a surgeon rests upon his Traits de pathologie externe (5 vols., 1838-41), 
which was a popular manual and reached a fifth edition in 1860. He 
invented serres-fines, was the first to inject a solution of nitrate of silver 
into the uterine cavity, and contributed largely to our knowledge of 
syphilis, successfully opposing Ricord, the great authority of the day, in 
some important points relating to this disease. 

Joseph Gensoul (1797-1858) studied at Lyons and Paris, graduating 
in 1824, and in 1826 became chief surgeon of the Hotel Dieu of Lyons, 
where he soon acquired celebrity as a bold and skilful operator. He first 
(in 1826) excised the entire upper jaw, in 1827 he removed the parotid 
gland, and, first in France, excised half of the lower jaw, and he first 
treated varices with caustic. He wrote very little, his chief publication 
being his Lettre ohirurgieale sur quelques maladies graves du sinus max- 
illaire et de I'os maxillaire inferieur (1833). 

Amed6e Bonnet (1802-58) studied at Paris, where he graduated in 
1832, and in 1833 obtained the position of surgeon to the Hotel Dieu 
at Lyons by concours, after which he became a professor in the school, 
and was soon celebrated as a teacher. His principal publications 
are — Traits des sections tendineuses et musculaires dans la strabisme, la 
myopic, etc. (1841), Traiti des maladies des articulations (2 vols., 1845), 
and Traiti de thSrapeutique des maladies articulaires (1853), which latter 
remain as valuable contributions to the surgery of the joints. 

Charles Gabriel Pravaz (1791-1853) studied at Paris, graduated in 
1824, and devoted himself to orthopaedic surgery, associating himself 
with Jules Gu6rin in a private orthoptedic hospital. In 1835 he settled 
in Lyons. His principal contributions to surgery relate to orthopsedia 



112 THE HISTORY AND LITERATURE OF SURGERY. 

— which he was one of the first to place on a scientific foundation — to 
the use of perchloride of iron, to the use of fine hollow needles for the 
injection of varices or erectile tumors, etc. 

Eaoul Henri Joseph Scoutettin (1799-1871), a native of Lille, 
entered the army, and graduated at Paris in 1822. He became one of 
the most distinguished of French military surgeons, was professor in the 
school at Metz in 1836, and in 1840 held the same position in the mili- 
tary hospital at Strasburg. In 1854 he was in charge of the military 
hospital in Constantinople and Pera, after which he returned to Metz, 
and was in charge of the military hospital until his death. He was a 
voluminous writer on matters connected with military medicine and 
surgery, and an excellent operator. He successfully performed trache- 
otomy on his infant daughter six weeks old. 

Jean Baptiste Lucien Baudens (1804-57) studied in Paris, entered 
the army medical service in 182-3, and graduated in 1829. He served 
in Africa from 1830 to 1837, in 1838 became professor in the hospital 
at Lille, and in 1842 professor at Val de Grfice. He was a distin- 
guished military officer, and made numerous contributions to military 
surgery, among which may be mentioned his Clinique. des plaies d'armes 
& feu (1836) and his La guerre de Crimie, les campements, les abris, les 
ambulances, les hSpitaux, etc., first published in the Revue des deiix- 
mondes in 1857, and in separate form in 1858. 

Jean Gaspard Blaise Goyrand (1803-66) studied at Paris, graduated 
in 1828, and, returning to his native city Aix, became chief surgeon to 
the hospital, and one of the most distinguished of the French provincial 
surgeons of his day. He made important contributions to the literature 
of amputations, fractures of the lower end of the radius, operations for 
loose bodies in the joints, extirpation of the tongue, urethral fistula, 
etc. His principal work is his Clinique chirurgicale ; m&moires et obser- 
vations de chirurgie, etc. (Paris, 1870), published after his death by Dr. 
Silbert. 

Jules Roux (1807-77), a native of Aix, studied at Toulon, entered 
the naval medical service in 1828, and became professor in the school 
of Toulon in 1842. He was distinguished as an operator and clinical 
teacher, devised a useful modification for disarticulation of the foot, 
made improvements in the operation of trephining, and was the first to 
make use of iodine injections in disease of the shoulder-joint. He made 
numerous contributions to the journals and learned societies, but pub- 
lished no important sepai-ate work. 

To the fourth period (from 1847 to the present time) belong, in addi- 
tion to those already referred to and those who are still living and do 
not yet belong to history, a number of well-known surgeons, of whom 
the most prominent at Paris were Malgaigne, Nglaton, Denonvilliers, 
Chassaignac, Richet, Follin, Broca, Dolbeau, Gosselin, and Tr^lat. 

Joseph Franfois Malgaigne (1806-65), a native of the Vosges, son of 
an offioier de santi, studied at Paris, graduating in 1831, and after a short 
term of military service in Poland settled in Paris, where he became a 
surgeon of the Central Bureau in 1835, and began to teach surgical 
anatomy. He was _ successively surgeon to the Hospital St. Louis and 
to La Charitg, and in 1850 won by concours the chair of operative sur- 
gery vacated by Blandin. 



THE HISTORY AND LITERATURE OF SURGERY. 113 

Malgaigne was the greatest surgical historian and critic which the 
world has yet seen, a brilliant speaker and writer, whose native genius, 
joined to incessant labor, brought about a new mode of judging of the 
merits of surgical procedures — the mode of statistical comparison joined 
to experiment. He was not a great operator, and although he made 
some improvement in the art, such as his hooks for the treatment of 
fractures of the patella, his suggestion of suprathyroid laryngotomy, 
etc., these are of small importance as compared with his work of explod- 
ing errors, exposing fallacies in reasoning, and bringing to bear upon 
the work of the present day the light of the experience of the past, of 
which his treatise on fractures and dislocations aifords many excellent 
examples. The reports of his speeches in the Bulletins of the Academy 
of Medicine are among the most delightful reading in surgical literature. 

Auguste Nelaton (1807-73), the son of a French soldier, a native 
of Paris, studied at the Hotel Dieu under Dupuytren and at the Found- 
ling Hospital, graduating in 1836. He became professor of clinical 
surgery in 1851, was for many years a colleague of Malgaigne at the 
Hospital St. Louis, and for the last fifteen years of his life was the most 
popular surgeon in Paris. He was, in fact, in many respects, the best sur- 
geon whom France has produced during the century, being unsurpassed 
as a diagnostician, as an operator, and as a clinical teacher, and was a 
modest, quiet gentleman who attacked no one and befriended many. He 
made many improvements in surgical technique, among which was the 
porcelain-headed probe which he devised for demonstrating the presence 
of the bullet in Garibaldi's ankle-joint. He brought into French prac- 
tice the principle, so strongly insisted on by Gruthrie, of ligating both 
ends of a wounded artery within the wound for either primary or 
secondary hemorrhage, improved the methods of treatment of naso- 
pharyngeal tumors, first clearly demonstrated retro-uterine haematocele, 
and brought ovariotomy into good repute in France. He wrote com- 
paratively little, his chief publication being his jSlements de pathologie 
chirurgicale (5 vols., 1844-59, of which the last two volumes were pub- 
lished by A. Jamain). The only publication of his clinical lectures is 
that made in 1855 by Dr. W. F. Atlee of Philadelphia from his own 
notes — a book which is not nearly as well known as it deserves to be. 

Charles Pierre Denonvilliers (1808-72) studied at Paris and grad- 
uated in 1837; became a surgeon of the Central Bureau in 1840, in 
1842 chief of the School of Practical Anatomy and surgeon of the 
Hotel Dieu, and in 1856 professor of surgery. He was, however, more 
of an anatomist than a surgeon, although he was a good operator, 
especially in the field of plastic surgery. His most important services 
to medicine were rendered in his capacity as inspector-general of public 
instruction for medicine, to which he was appointed in 1858. 

fidouard Pierre Marie Chassaignac (1804—79) studied at Nantes and 
Paris, graduating in 1835, and gave private courses in anatomy and 
operative surgery, but did not become a professor in the faculty, 
although he often competed for this position. He became surgeon to 
the LariboisiSre in 1852. His most important contributions to surgery 
were the introduction of the method of the drainage of wounds and 
abscesses, his method of dressing wounds by complete occlusion, and his 
invention of the 6craseur. 

Vol. I.— 8 



114 THE HISTORY AND LITERATURE OF SURGERY. 

Louis Alfred Eichet (1816-91), a native of Dijon, studied in Paris, 
graduating in 1844. He was surgeon to the hospitals Lourcine, St. 
Antoine, and La Pitie, and in 1 864 became professor of clinical surgery 
in the faculty. His principal work was his Traiti pratique d'anatomie 
midico-chirurgicale (Paris, 1857; 4th ed. 1873). 

Eugfene Follin (1823-67), a pupil of Velpeau, was a skilled anatom- 
ist and excelled in diagnosis. He introduced the use of the ophthal- 
moscope in France. His early death left his TraiU iUmeiitaire de 
pathologie externe unfinished, but it was continued and completed in six 
volumes by Duplay, and is a work of much practical value. His 
contributions to surgery are characterized by freedom from exaggera- 
tion and by sound sense. 

Paul Broca (1824-80), the son of an army surgeon, studied at Paris, 
graduating in 1849, immediately after which he became prosector at the 
Fcole pratique. In 1853 he became assistant professor in the faculty, 
and in 1867 professor of surgery, soon after which he exchanged this 
chair for that of clinical surgery. He was successively surgeon to the 
hospitals St. Antoine, La Pitig, Des Cliniques, and Necker. He was an 
original investigator of a high order, as is shown by his researches on 
cerebral localization, aphasia, etc. Distinguished as an anatomist, a 
pathologist, and a surgeon, he devoted himself in the latter part of his 
life more especially to anthropology, of which he may almost be said to 
have been the founder in France. He was the first to trephine for an 
abscess of the brain, the location of which was determined by his study 
in the localization of function of that organ. In fact, his studies may 
be said to be the foundation of modern brain-surgery. 

Henri Ferdinand Dolbeau (1830-77) studied at Paris, graduating in 
1856, became hospital surgeon in 1858, serving successively at the 
Hospital for Children, Necker, and the H6tel Dieu, where he replaced 
Jobert in 1865, and in 1868 became professor in the faculty. He 
contributed to our knowledge of club-foot, of cartilaginous tumors, of 
epispadias, and of spina bifida, suggested lithotrity through perineal 
section in cases of large calculus, and was an excellent practical teacher. 
His principal works are De l'6pispadias (1861), Traiti pratique de lapierre 
dans la vessie (1864), and Legons de clinique chirurgioale (1867). 

Athanase L6on Gosselin (1816-87), a native of Paris, graduated in 
1843, and became surgeon to the hospitals, and in 1858 professor of 
surgery in the faculty, and surgeon to La Charity in 1867. He contrib- 
uted to journals many valuable papers which were collected and pub- 
lished in his Clinique chirurgicale de I'hSpital de la Gharit& (2 vols., 
1873 ; 3d. ed. 1879, and translated into English, Philadelphia, 1878). 

Ulysse Trelat (1828-90), the son of a physician, and a native of Paris, 
studied at Paris, graduating in 1854. He became prosector in 1856, in 
1857 assistant professor in surgery to the faculty, and in 1860 surgeon 
of the Central Bureau, serving successively at the hospitals Maternity, St. 
Antoine, St. Louis, La Piti6, and La Charitg. He became professor of 
surgical pathology in the faculty in 1872. He was an eloquent speaker 
and fond of speaking, a very popular clinical teacher, and the first in 
France to recognize the importance of the new antiseptic method. 
His publications were mainly in journals and transactions ; they relate 
chiefly to plastic surgery of the palate and of the face, to hernia, tuber- 



THE HISTORY AND LITEBATUBE OF SUBGEBY. 115 

culosis of the tongue, oesophagotomy, etc. His Legons de dinique 
chirurgicale appeared in 1877, and his Clinique chirurgioale (2 vols.) in 
1891. 

In addition to these may be mentioned the following : 

Joseph Pierre El^onor Pdtrequin (1809-76) studied at Paris, gradu- 
ating in 1835, in 1838 became an assistant surgeon in the Hotel Dieu at 
Lyons, and in 1855 became professor of surgery in the school. He was 
a learned historian in matters pertaining to the art, a skilled physician 
as well as surgeon, and a voluminous writer. His principal publications 
are — Traiti d'anatomie medioo-chirurgicale et topographique (1844 ; 2d 
ed. 1857, translated into German, 1845), Clinique chirurgicale de I'Hdtel 
JDieu de Lyon (1850), MManges de chirurgie et de m^decine (1870, 1873, 
1877), and Chirurgie d'Hlppocrate (2 vols., 1878). 

Joachim Albin Cardozo Cazado Giraldgs (1807-75), a native of 
Portugal, studied at Paris and graduated in 1836. In 1848 he became 
a surgeon of the Central Bureau, and was appointed to the Children's 
Hospital. The results of his work in this hospital appear in his Legons 
cliniques sur les maladies chirurgicales des enfants, do. (1869). 

Charles Emmanuel SMillot (1804-83), a native of Paris, studied 
under Boyer and Roux, and in 1824 at the Val de Grice. He gradu- 
ated ia 1829, after which he entered the military service, and in 1836 
became professor of operative surgery at Val de Grace. In 1841 he 
became professor of surgery at Strasburg by concours, succeeding B6gin. 
He made many valuable contributions to surgery, relating, among other 
things, to dislocations, plastic operations, urethrotomy, pyaemia, the sur- 
gery of the bones, gastrotomy — to which he gave the name — operations 
for cancer of the tongue, etc. In 1840 he performed the first successful 
amputation at the hip-joint in Paris. 

Paul Louis Benoit Guersant (1800-70), son of a celebrated Paris 
physician, studied at Paris, graduated in 1828, and in 1833 became 
surgeon to the Children's Hospital by concours, remaining in this posi- 
tion until 1 860. His principal work is his Notices sur la chirurgie des 
enfants (1864-67; translated into English, 1873). 

Jules E6ne Gu6rin (1801-86), a native of Boussu (at present in Bel- 
gium), studied at Paris, being a pupil of Boyer and Roux, and graduated 
in 1826. In 1830 he founded the Gazette midicale de Paris, of which 
he was the editor for forty years. He devoted himself to orthopaedic 
surgery, having established a private orthopaedic hospital, and in 1838 
published his first memoir on deformities of the osseous system, which 
was followed by a long series of similar papers. A portion of these 
have been collected and published under the title OEuvres du docteur 
Jules GuSrin, etc. (Paris, 1882), said to have been intended to fill 16 
volumes, with 100 plates, but which has never been finished. As a 
controversialist and journalist he was better known and better liked 
among non-professional persons than among those of his own pro- 
fession. 

F6lix Adolphe Richard (1822-72) studied at Paris, and graduated 
in 1848. He became surgeon of the Central Bureau in 1852, and as- 
sisted N^laton in his clinical teaching. His principal work is his Pratique 
journalise de la chirurgie (1868). 

When the Austrian Netherlands became a part of the French Re- 



116 THE HISTORY AND LITERATURE OF SURGERY. 

public, in 1795, the five medical schools in Belgium were suppressed, as 
those in France had been, and with much the same results. Each large 
town attempted to regulate the matter by local examinations and by the 
establishment of schools of an inferior class, mainly devoted to giving 
instruction in surgery and obstetrics to uneducated men. When the 
kingdom of the Netherlands was created in 1815 the Universities of 
Ghent and Lifege were established and the old University of Louvain 
was rehabilitated. In organizing these schools a strong German element 
was introduced, and it was ordered that the lectures should be given in 
Latin. The result was a failure, for Paris was the great medical school 
of the day, and the Belgian students went there. The Eevolution of 
1830 closed the universities, and in 1835 medical teaching was placed 
substantially on the French basis. 

The leading surgeons of Holland in this century have been Hen- 
driksz, Onsenoort, Tilanus, and Ranke. 

Pieter Hendriksz (1779-1845) served in the army, studied at Gron- 
ingen, where he began to teach surgery in the hospital in 1810, in 1827 
was called to Leyden, and in 1828 to Amsterdam as professor, which 
position he resigned in 1832. He published descriptions of his opera- 
tions in the Groningen hospital in 1816, in 1822, and in 1828. 

Anthony Gerard van Onsenoort (1782-1841), a surgeon's apprentice, 
served in the army, began to teach in Lowen in 1817, and in 1822 con- 
tinued teaching in Utrecht. He published De miliiaire chirurgie (1832) 
and De operative heelkunde (3 vols., 1835-37), besides several works on 
ophthalmology. 

Christian Bernard Tilanus (1796-1883), a native of Harderwijk, 
studied at Utrecht, graduating in 1819, and then in Paris under Dupuy- 
tren and Lisfranc, and in 1828 became professor of surgery and obstet- 
rics in the school at Amsterdam, where he was the first to give regular 
clinical teaching in surgery in the hospital. He ceased teaching in 
1872. 

Hans Rudolph Ranke (1849-87), a native of Kaiserwerth and a 
pupil of Volkmann, graduated at Halle in 1874, and in 1876 became 
professor of surgery at Groningen. He contributed a number of papers 
to journals, but published no important work. 

At the beginning of the nineteenth century the leading Italian sur- 
geons were Scarpa, Palletta, Monteggia, and Vacca Berlinghieri. 

Antonius Scarpa (1762-1832) studied at Padua under Morgagni, 
graduating in 1770 at the age of eighteen. Two years later he was 
appointed professor of anatomy and theoretical surgery at the University 
of Modena, and in 1783 was appointed by Joseph II., emperor of 
Austria, as professor of anatomy at the University of Pavia, to which 
was added in 1787 the chair of clinical surgery. He retained both these 
professorships until 1803, when he gave up anatomical teaching, but con- 
tinued to teach in clinical surgery until 1812. He was the most cele- 
brated Italian anatomist and surgeon of his day, and his talent as an 
artist enabled him to illustrate his discoveries in a manner which at once 
attracted general attention. His name is perpetuated in surgery by 
" Scarpa's triangle." 

Giovanni Battista Palletta (1747-1832) graduated at Padua in 1769, 
and in 1787 became chief surgeon of the Hospital Maggiore in Milan, 



THE HISTORY AND LITERATURE OF SURGERY. 117 

and gave lessons in anatomy and clinical surgery. He was greatly 
beloved, and his death was considered as a public calamity in Milan. 

Giovanni Battista Monteggia (1762-1815) became professor of anat- 
omy and surgery in Milan in 1795, and was associated with Scarpa in 
the preparation of Istituzioni di chirurgia (5 vols., 1802-03 ; 4th ed., 
7 vols., 1829-30). 

Andrea Vacca Berlinghieri (1772-1826), son of Francesco Vacca 
Berlinghieri, professor of medicine at Pisa, studied at Paris under 
Desault and at London under John Hunter, and, returning to Pisa, 
graduated in 1791. In 1801 he became professor of surgery at Pisa, 
and soon acquired a great reputation. 

In the middle of the century the best-known Italian surgeons were — 
Luigi Porta (1800-75), who studied at Pavia, was for three years in 
Vienna, and became professor of clinical surgery at Pavia in 1832, 
which position he held until his death ; and Francesco Eizzoli (1809-80), 
professor of surgery and obstetrics in Bologna in 1840, who was distin- 
guished as an operator and teacher. 

The scheme of medical studies adopted in Austria in 1810 prescribed 
a five years' course in medicine or the higher surgery, and a two years' 
course for country doctors. In 1822 the course at the Military Medico- 
chirurgical Academy, or Josephinum, was extended to five years, and 
this college had the right to grant degrees. In 1849 much more power 
was given to the professors in the various universities as to the arrange- 
ment of studies, but a complete separation between the faculties and the 
medical associations was not made until 1873. In 1872 separate diplo- 
mas for surgery were abolished. 

In Prussia a system of medical study was arranged in 1825. It pro- 
vided for physicians who studied at the universities, and for what were 
called surgeons of the first and second class. The surgeons of the 
second class were surgeons' apprentices Avho served for a short time 
in a military hospital or attended a few lectures at a medico-chirurgical 
college ; their examination was a very easy one, but demanded some 
knowledge of anatomy, and they were mostly comparatively uneducated 
men of an inferior class. The surgeons of the first class had to study 
at a university or a medico-chirurgical school for three years, and were 
not required to know Latin, as were the physicians, showing that sur- 
gery was still considered inferior to medicine. In 1852 it was ordered 
that there should be but one class of doctors, but the obtaining a med- 
ical degree did not give the right to practise. At present the education 
and the standing of physicians and of surgeons are the same throughout 
the empire. 

During the first fourteen years of the nineteenth century the Napo- 
leonic wars produced an urgent demand for army surgeons, especially in 
Austria, which was often the field of conflict. Vienna had the leading 
surgical schools in Germany at that time, founded by Leber in connec- 
tion with the university, and by Brambilla in connection with the Mili- 
tary Medical School, and the principal surgeons in Southern Germany 
after Leber were von Kern, Rudtorffer, "Wattmann, and Zang. 

Vincenz Sebastian von Kern (1760-1829), professor of surgery at 
Laibach in 1797, became professor of practical and clinical surgery in 
the Vienna University in 1805, and exercised a powerful influence on 



118 THE HISTORY AND LITERATURE OF SURGERY. 

the development of surgery and surgical teaching in Germany and 
Northern Italy until his resignation in 1824. He greatly simplified 
the prevailing treatment of wounds, returning to the water-dressings 
of Magatus and rejecting plasters and salves, and was a skilful operator 
and an excellent teacher. 

Franz Xav. Rudtorffer (1760-1833) commenced teaching in the great 
Vienna Hospital in 1801, and in 1810 succeeded Leber as professor of 
surgery, which position he held until he retired in 1821. 

Joseph von Wattmann (1779-1866), son of a surgeon and pupil of 
von Kern, became professor at Laibach in 1816, at Innsbruck in 1818, 
and at Vienna in 1824, retiring in 1848. He was a celebrated operator, 
and gained great reputation as a teacher. 

Christoph B. Zang (1772-1835) graduated at Vienna, entered the 
Austrian army, and in 1806 became professor of surgery in the Josephi- 
num. He published DarsteUung blutiger heilkunstlerischer Operationen 
(4to, 1813-21) — an excellent manual of operative surgery, which reached 
a third edition and was translated into Italian. 

In North Germany the principal surgeons of this period were 
Mursinna, Rust, C. J. M. Langenbeck, v. Walther, Hesselbach, and 
Briinninghausen. 

Christian Ludwig Mursinna (1744-1823), a barber's apprentice, en- 
tered the Prussian army in 1761 under Theden. In 1787 he became sur- 
geon-general, and professor of surgery in the military medical school 
at Berlin, which position, in connection with that of surgeon to the 
Charite, he retained after his retirement from military service in 1809. 
He was a skilful operator and a good administrator, who greatly, im- 
proved the medical service in the Prussian army, but wrote little 
except occasional addresses and papers for journals. 

Joh. Nepomuk Rust (1775-1840) studied in Vienna and Prague, and 
became professor of surgery at Cracow in 1803. From 1810 to 1815 
he was one of the surgeons of the General Hospital in Vienna, and in 
1816 he succeeded Mursinna in the army medical school at Berlin, 
becoming professor in the University of Berlin in 1824. 

Conrad Joh. M. Langenbeck (1776-1851) studied at Jena, Vienna, 
and Wiirzburg, and in 1802 settled in Gottingen, where he soon began 
to teach anatomy and surgery. In 1814 he became professor of anatomy 
and surgery and surgeon-general of the Hanoverian army. In 1802 he 
published a treatise on lithotomy ; in 1806 the first volume of his Biblio- 
thek fur die Chirurgie, of which the eighth and last volume appeared 
in 1828 ; and in 1822 the first volume of his Nosologic unci Therapie 
der chirurgischen Kranhheiten, etc., of which vol. v. appeared in 1850. 
He was a skilful anatomist and operator, modifying and improving the 
technique, and a celebrated teacher. 

Philip Franz v. Walther (1782-1849) was educated at Heidelberg and 
Vienna, and became professor and surgeon to the hospital at Bamberg 
when he was only twenty-one years old. In 1804 he became professor 
of physiology and surgery at Landshut, and soon acquired a high repu- 
tation as an operator and teacher. In 1818 he accepted a call to the 
newly-organized university at Bonn, where he soon became the leading 
German surgeon of his time. In 1 830 he went to Munich as professor 
of surgery in the university, which had been transferred to that city 



THE HISTORY AND LITERATURE OF SURGERY. 119 

from Landshut, and as director of the surgical clinic in the General 
Hospital, in which positions he remained until his death. He was the 
founder of modern surgery in Bavaria, and his physiological training 
was of great assistance in his surgical teaching. He wrote a System der 
Chirurgie (1833) and numerous papers for periodicals. 

Franz Caspar Hesselbach (1759-1816) was a pupil of Von Siebold at 
Wiirzburg, and his assistant in anatomical demonstrations. His principal 
contributions to surgery are his papers on hernia, published in 1806, 
1814, and 1815, in the first of which he gives the first distinct descrip- 
tion of the two forms of inguinal hernia. 

Hermann Joseph Briinninghausen (1761-1834) was professor of sur- 
gery at Wiirzburg in the early part of the century, and published his 
JSrfahrungen und Bemerhungen iiber die Amputation in 1818. 

Between 1825 and 1850 the leading German surgeons were Graefe, 
Dieffenbach, and Chelius, in addition to the survivors of those already 
referred to. 

Carl Ferdinand von Graefe (1787-1840) studied at Dresden, Halle, 
and Leipzig, in 1810 became professor and director of the surgical clinic 
in the newly-founded University of Berlin, and from 1813 to 1815 
served as surgeon-general of division in the army. In 1816 he first 
performed suture for congenital cleft palate, and then devised blepharo- 
plasty and rhinoplasty, which he introduced to notice. He was one of 
the first to resect a portion of the lower jaw, and the first in Germany 
to ligate the innominate artery. 

Johann Friedrich Dieffenbach (1792-1847) was a native of Konigs- 
berg, where he studied from 1818 to 1820, when he went to Bonn and 
became the pupil of von Walther. In 1821 he went to Paris and Mont- 
pellier, attending the clinics of Dupuytren and Delpech, and in 1822 
graduated at Wiirzburg, his thesis, NonnuUa de regeneratione et trans- 
plantations, indicating the trend of his studies. In 1823 he went to 
Berlin and devoted himself largely to plastic surgery. In 1829 he 
became surgeon to the Charite, and in 1832 professor extraordinary in 
the university, at which time he began his work in orthopaedic surgery. 
In 1829 he devised the section of the tendons of the ocular muscles for 
strabismus, which made a great sensation in the surgical world. In 
1840, after the death of von Graefe, he became professor in the uni- 
versity and director of the surgical clinic. He made many valuable 
contributions to methods in plastic surgery and tenotomy, which are 
summed up in his Operative Chirurgie (2 vols., 1845-48). His enthusi- 
asm for novelties led him into some blunders, as in his publications on 
the cure of stammering by subcutaneous section of the muscles of the 
tongue, but he was a great surgeon, a most skilful operator, and an 
extremely popular clinical teacher. 

Max. Jos. von Chelius (1794-1876), a native of Mannheim, gradu- 
ated at Heidelberg in 1812, after which he studied under Walther at 
Landshut and Vienna, and became professor at Heidelberg in 1819. 
Here he soon founded a surgical and ophthalmological clinic, and in 
1822-23 published his Handbueh der Chirurgie, which for the next 
twenty-five years was the best-known manual in Germany, and indeed 
in Europe, having been translated into English, French, Italian, Danish, 
and Dutch, and the eighth German edition having been issued in 1857. 



120 THE HISTORY AND LITERATURE OF SURGERY. 

The English translation by South (in 1847) is especially valuable,^ being 
nearly doubled in size by the notes of the translator, and permitting of 
a direct comparison of the English and German surgery of that day. 
He was one of the best-known surgeons in Europe and had many dis- 
tinguished pupils. 

To this period also belong von Textor, Jaeger, Blasius, AVutzer, von 
Ammon, Wernher, Kuhl, Grossheim, Fricke, Mojsisovics, Holscher, 
and Benedict. 

Kajetan von Textor (1782-1860) studied at Landshut under von 
Walther and graduated in 1 808, after which he spent two years in Paris 
mainly following the teaching of Boyer, and a season at Pavia under 
Scarpa. In 1816 he became professor of surgery at Wiirzburg, and 
held this position until 1853 with the exception of the years 1832-33. 
He published Grundzuge zur Lehre der chirurgischen Operationen, etc., 
in 1835, and some small monographs. His chief surgical contributions 
related to resections, in which he was a very skilful operator. His son 
Carl (1815-80) became assistant professor of surgery at Wiirzburg in 
1850, and contributed a number of surgical papers to periodicals. 

Michael Jaeger (1795-1838) graduated at Wiirzburg in 1819, and in 
1826 succeeded Schreger as director of the surgical clinic at Erlangen, 
becoming professor of surgery in 1831. In 1832-33 he was professor 
of surgery at Wiirzburg during von Textor's absence, after which he 
returned to his old position at Erlangen. He contributed materially to 
the literature of resections and of diseases of the bones and joints. 

Ernst Blasius (1802-75), a native of Berlin, studied at the Friedrich 
Wilhelm Institut and graduated in 1823, after which he served four 
years in the army, and then settled in Halle, where he became professor 
of surgery in 1834. His principal work was his Handbuch der Ahiurgie 
(3 vols, and atlas, 1830-33), but he also published collections of cases 
and essays, a treatise on amputations, and numerous papers in the 
journals. 

Carl Wilhelm Wutzer (1789-1863), a native of Berlin, studied at 
the PepiniSre, served in the army, and became director of the surgical 
school at Miinster in 1821. In 1830 he succeeded Weinhold as pro- 
fessor of surgery at Halle, and in 1833 took the same chair at Bonn. 
He contributed numerous articles to periodicals, but wrote no important 
works, and is best known as the originator of the method for the radical 
cure of inguinal hernia which bears his name. He was a skilled anat^ 
omist, a good operator, and a painstaking, careful teacher. 

Friedrich August von Ammon (1799-1861) studied in Leipzig and 
Gottingen, graduating in 1821, and settled in Dresden, where he became 
professor in the surgical school in 1828, resigning in 1837. The greater 
part of his numerous publications relate to ophthalmology, but he also 
devoted much attention to plastic surgery and to orthopsedia. In con- 
nection with Baumgarten he published Die plastische Chinirgie.nach 
ihren Leistungen kritisch dargestellt (1842), and in the same year appeared 
his Die angeborenen Krankheiten des Menschen, etc. (in folio with plates), 
which is a classic. Another iinely-illustrated work is his Klinische 
Darstellung der Krankheiten und Bildungsfehler des menschliohen Auges, 
etc. (fol., 1838-41). 

Adolph Wernher (1809-83) graduated in 1832 at Giessen, where 



THE HISTORY AND LITERATURE OF SURGERY. 121 

he became professor of surgery and director of the surgical clinic in 
1837, retiring in 1878. His Handbuch der allgemeinen und speciellen 
Chirurgie (4 vols., 1846-47) was an excellent manual, of which the first 
volume of a second edition appeared in 1862-63. 

Karl August Kuhl (1774-1840) studied at Leipzig, graduating in 
1803, after which he went to Vienna, London, and Paris. In 1817 he 
became assistant professor, and in 1824 professor, of surgery at Leipzig. 
He was a bold and skilful operator, and ligated the innominate, the 
subclavian, and both carotids, all of which cases he described, but he 
wrote no important work and made no special contributions to surgical 
progress. 

Ernst Leopold Grossheim (1799-1844), a pupil of the Friedrich 
Wilhelm Institut in Berlin, was an army surgeon and a teacher in the 
surgical school at Miinster, who published a Lehrbuch der operativen 
Chirurgie (3 vols., 1830-35). 

Joh. Carl George Fricke (1790-1841) studied at Gottingen, where he 
graduated in 1810, after which he studied in Berlin under von Graefe. 
In 1814 he settled in Hamburg and became surgeon of the General 
Hospital. He published the records of his clinical work in the Annalen 
der cMrurgischen Abtheiluiig des allg. KrankenJmuses in Hamburg (2 
vols., 1828-33), and in various journals, especially in the Zeitschriftf. d. 
ges. Medicin, of which he was one of the editors. His contributions 
relate to blepharoplasty, the non-mercurial treatment of syphilis, the 
treatment of orchitis by compression, the torsion of arteries, the forceps 
and vaginal speculum known by his name, etc. 

George Mojsisovics (1799-1860), a Hungarian, studied in Budapest 
and Vienna and graduated in 1826. In 1828 he became assistant in the 
surgical school at Vienna, and in 1832 first surgeon of the General 
Hospital. He published nothing of any importance. 

George P. Holscher (1792-1862) studied at Gottingen, and in Lon- 
don under Astley Cooper, and settled in Hannover, where he became a 
teacher in the surgical school and editor of the Hannoversohe Annalen 
fur die gesainmte Heilkunde (1836-47). His publications were almost 
entirely journal articles. 

Traugott Wilh. Gustav Benedict (1785-1862) studied at Leipzig, grad- 
uating in 1810, and in 1812 became professor at Breslau, where he 
acquired a reputation as an ophthalmologist. His principal surgical 
publication is his Lehrbueh der allgemeinen Chirurgie und Operationslehre 
(1842). 

The next group of German surgeons to be noted includes von Lang- 
enbeck, Stromeyer, Heyfelder, von Pitha, Schuh, von Bruns, Giinther, 
Middledorpf, Busch, Linhart, Wagner, and Baum. 

Bernard Eudolph Konrad von Langenbeck (1810-87), the most dis- 
tinguished German surgeon of the nineteenth century, took his doctor's 
degree at Gottingen in 1835, became professor of surgery at Kiel in 
1842, and succeeded Dleffenbach in the chair of surgery at Berlin in 
1847. In conjunction with his pupils, Billroth and Gurlt, he established 
the Archiv fur klinisohe Chirurgie in 1861, a journal which has con- 
tained the most important contributions to surgery made by German 
surgeons since that date, and he was the founder of the Deutsche Gesell- 
schaft filr Chirurgie in 1872. Langenbeck wrote no manual or system 



122 THE HISTORY AND LITERATURE OF SURGERY. 

of surgery, but contributed numerous papers to the Arehiv fur Minische 
Ghirurgie, his largest work being his Chirurgische Beohachtungen aus dem 
Kriege (251 pp. 8vo, Berlin, 1874). His operations and improvements 
of the technical methods of surgical operations are too numerous to 
mention. Some of the most important of them relate to plastic surgery 
of the nose and of the hard palate, and to operations for tumors at the 
base of the cranium, for removal of the tongue, etc. His greatest con- 
tribution to surgery, however, has been his pupils, among whom may be 
numbered nearly every prominent surgeon in Germany of the present 
day. 

Georg Friedrich Louis Stromeyer (1804-76), son of Chr. Fr. Stro- 
meyer, surgeon to the king of Hannover, studied at Hannover, Gottin- 
gen, and Berlin, and graduated in 1826. In 1829 he began to teach 
in the surgical school at Hannover, in 1838 succeeded Jaeger as pro- 
fessor of surgery at Erlangen, in 1842 accepted the same chair in Frei- 
burg, and in 1847 succeeded Langenbeck at Kiel. He became surgeon- 
general of the Schleswig-Holstein arm}', serving in the war of 1849, 
and surgeon-general of the Hannoverian army in 1854, serving in the 
war of 1866. His chief contributions to the art were connected with 
orthopaedic surgery and tenotomy, and especially with resections in 
military surgery. He performed subcutaneous section of the tendo 
Achillis in 1831, being the first after Delpech to do so. His principal 
publications were Beitrdge zur operativen Orthopddik (1838), Handbuch 
der Chirurgie (2 vols., 1844-48), and Maximen der Kriegsheilkunst (1855). 

Johann Ferdinand Heyfelder (1798-1869), student at Berlin, Wiirz- 
burg, and Breslau, graduating in 1820, in 1841 succeeded Stromeyer as 
professor of surgery at Erlangen, which position he resigned in 1854. 
The latter part of his life was spent in St. Petersburg. He was a 
learned surgeon, a skilful operator, a teacher of great reputation, and a 
voluminous writer upon many subjects besides surgery. He is best 
known by his treatise Ueber Resectionen und Amputation en (1854), 
which is a standard work upon the subject. His son, Oscar Heyfelder 
(1828-?), studied at Heidelberg and Erlangen, graduating in 1851, 
and entered the Russian army medical service in 1859. He published 
Lehrbuch der Resectionen (2d ed. 1863, and translated into French in 
the same year), Kriegschirurgisohes Vade Mecum (1874), and numerous 
articles in the journals. 

Franz von Pitha (1810-75), a native of Bohemia, studied at Prague, 
graduating in 1836, and in 1843 succeeded Fritz as professor of surgery 
in the University of Prague, in which position he soon obtained a high 
reputation as a teacher. In 1854 he accepted the chair of surgery in 
the Medico-chirurgical Josephs Academy in Vienna, re-established for 
the purpose of training medical officers for the Austrian army. His 
name is best known in connection Avith the Handbuch der allgemeinen 
und speciellen Chirurgie, edited by Billroth and himself (1865-82). He 
was a skilful diagnostician and operator and a cultured and polished 
gentleman. 

Franz Schuh (1804-65) studied in Vienna, graduating in 1831, 
became surgeon to the General Hospital in Vienna in 1837, and pro- 
fessor of surgery in 1842. He was an excellent practical teacher and 
writer, aided much in increasing the reputation of the school, and con- 



THE HISTORY AND LITERATURE OF SURGERY. 123 

tributed numerous papers to the journals. His principal books are — 
TJeber die Erkenntniss der Pseudoplasmen (1851), Pathologie und Therapie 
der Pseudoplasmen (1854), and Abhandlungen aus dem Gebiete der Chi- 
rurgie und Operationslehre (published after his death, in 1867). 

Victor von Bruns (1812-83), student at Tubingen, graduating in 
1836, became professor of surgery at Tubingen in 1843, which posi- 
tion he held until 1882. He was one of the founders of modern lar- 
yngology, and was the first to remove a laryngeal growth through the 
natural passages. His principal works are — Chirurgiseher Atlas (foL, 
1853-60), Handbuch der praktischen Chirurgie (2 vols., 1854-59), Die 
Laryngoskopie und die laryngoskopische Chirurgie (1865), Chirurgische 
Heilmittellehre (2 vols., 1868-73), Die galvanokaustisehen Apparate, eto. 
(1878), and Die Amputation der Gliedmassen durch Zirkelsohnitt mit 
vorderem Hautlappen (1879). 

Gustav Biedermann Giinther (1801-66) studied at Leipzig, graduat>- 
ing in 1824, and in the following year became an assistant to Fricke in the 
General Hospital at Hamburg. In 1831 he was appointed professor of 
surgery in Kiel, and in 1841 accepted the same position at Leipzig. 
He was a good anatomist and a careful, painstaking teacher, but was not 
distinguished as an operator. His principal work is his Lehre von den 
blutigen Operationen am menschlichen Korper (4to, 1859-65). 

Albrecht Theodor Middeldorpf (1824-68) studied at Breslau and 
Berlin, graduating in 1846, and in 1856 became professor of surgery at 
Breslau. He introduced the use of the galvano-cautery, made improve- 
ments in the treatment of fractures and of gastric fistula, and was one 
of the best clinical teachers of his time. His principal publications are 
— Beitrdge sur Lehre von den Knochenbruohen (1853), Die Galvano- 
caustik (1854), Ueberbliek iiber die Akidopeirastik (1856), and Com- 
mentatio de fistulis ventriouli externis, etc. (1859). 

Carl David Wilhelm Busch (1826-81), son of the celebrated obstet- 
rician Dietrich Wilh. Heinr. Busch, studied in Berlin, graduating in 
1848, and after extensive travels became an assistant in Langenbeck's 
clinic in 1851. In 1854 he accepted a call to Bonn as professor of 
clinical surgery, and remained there until his death. He was a volu- 
minous writer and made valuable contributions to the literature of gun- 
shot wounds, fractures and dislocations, diseases of the joints, plastic sur- 
gery, and hernia, the majority appearing in periodicals and transactions. 
His Lehrbuch der Chirurgie (2 vols., 1857-69) was his principal work. 

Wenzel von Linhart (1821-77), the son of a surgeon, studied in 
Vienna, graduating in 1844 ; became an assistant of Dumreicher, and 
in 1856 accepted a call to Wiirzburg as professor of clinical surgery. 
He was a skilled anatomist and operator and an excellent teacher. His 
principal works are his Compendium der chirurgisehen Operationslehre 
(1856; 4th ed. 1874) and Vorlesungen vber TJnterleibs-Hernien (1866; 
new ed. 1882). 

Carl Ernst Albrecht Wagner (1827-70), son of a celebrated physi- 
cian, studied in Berlin, graduating in 1848 ; became an assistant in 
Langenbeck's clinic, surgeon to the hospital in Dantzig in 1853, and in 
1858 professor of surgery in Konigsberg, where he acquired great repu- 
tation as a teacher. 

"Wilhelm Baum (1799-1883) studied at Konigsberg and Berlin, 



124 THE HISTORY AND LITERATURE OF SURGERY. 

graduating in 1822; continued his studies in Vienna, London, and 
Paris; in 1830 became surgeon in charge of the municipal hospital at 
Dantzig; in 1842 accepted the position of professor of surgery at 
Greifswald ; and in 1849 took the same chair at Gottingen, from which 
he retired in 1867. He was a learned man and a good teacher, but 
published nothing. 

To this period also belong Zeis, Stilling, and Heine. 

Edward Zeis (1807-68), a native of Dresden, studied at Leipzig, 
Bonn, and Munich, graduating at Leipzig in 1832, after which he 
settled in Dresden. From 1844 to 1860 he was professor of surgery at 
Marburg, at the end of which period he returned to Dresden and became 
surgeon to the city hospital. His principal publications are — Handbuch 
der plastischen Chirurgie (1838) and Die Liter atur und Geschichte der 
plastischen Chirurgie (1863-64). 

Benedict Stilling (1810-79) studied at Marburg, graduating in 1833, 
and became assistant in the surgical clinic. Soon after he settled in 
Cassel, where he remained for the rest of his life. He is much better 
known as a physiologist and investigator of the nervous system than he 
is as a surgeon, but he was the first ovariotomist in Germany, and between 
1856 and 1870 published several papers on strictui'e and on internal 
urethrotomy. 

Jacob von Heine (1800-79), of a family of instrument-makers and 
orthopaedists, student at Wiirzburg, graduated in 1827, and established 
an orthopaedic hospital in Cannstatt which became celebrated. His 
principal publications are — Beobachtungen iiber Ldhmungszustdnde der 
untern Extremitdten mid deren Behandlung (1840), Ueber spontane und 
congenitale Luxationen, etc. (1842), and Spinale Kinderldhmung (1860). 

Here also may be mentioned Carl Wilhelm von Heine (1838-77), 
son of Jacob v. Heine, and professor of clinical surgery in the new 
medical faculty of Innspruck in 1869, who wrote on gunshot wounds 
of the lower extremities, hospital gangrene, etc. ; August Gustav Herr- 
mann (1831-74) of Prague, author of Compendium der Kriegs-Chi- 
rurgie (1870); Fried. Wilh. Theodore Ravoth (1816-78) of Berlin, 
whose most important works relate to the treatment of hernia ; Ernst 
Ludwig Schillbach (1825- ?) of Jena, author of Beitrage zu den 
Resectionen der Knochen (1858-60) ; Hermann Demme (1802-67), pro- 
fessor of surgery in Berne, and his son, Carl Hermann Detnme (1831- 
64), author of some valuable papers on military surgery ; August Burow 
(1809-74) of Konigsberg, a pupil of DieflFenbach, author of numerous 
papers on ophthalmology, the open treatment of wounds, and plastic 
surgery ; Hermann Julius Paul (1824-77) of Breslau, author of Die 
conservative Chirurgie (1854 ; 2d ed. 1859) and Lehrbuch der speciellen 
Chirurgie (1861) ; Johann Balassa (1812-69) of Budapest, celebrated as 
an operator in lithotomy and plastic surgery ; and Joseph Blazina (1812- 
85), who graduated in 1841 at Prague, where he became professor of 
surgery. 

Between 1850 and the present time the leading surgeons of Ger- 
many, besides those already mentioned, and those who, being yet living, 
do not come within the scope of this paper, were Loeffler, Wilms, 
Simon, Thaden, Liicke, Hueter, Maas, Leisrink, Vogt, Volkmann, and 
Billroth. 



THE HISTORY AND LITERATURE OF SURGERY. 125 

Gottfried Friedrich Franz LoeiHer (1815-74) studied at the Fried- 
rich Wilhelm Institut in Berlin, and became one of the most distin- 
guished of the German army surgeons. His principal works are — 
Grundsdtze und Regeln fir die Behandlung der Sehusswunden im 
Kriege (1859) and Das preussisohe Militdr Sanitdtswesen und seine 
Reform (1868-69). 

Robert Ferdinand Wilms (1824-80) studied at Berlin, graduating in 
1846, and in 1848 became an assistant of Bartels in the Bethanien 
Hospital, of which he was placed in charge in 1862. He was one of 
the leading surgeons in Berlin, and was popular as a teacher, but wrote 
little beyond the reports of his hospital. 

Johann Dumreicher (1815-80) graduated at Vienna in 1838, became 
assistant to Wattmann, and took charge of one of the surgical clinics 
in 1849. He wrote very little. 

Christoph Jac. Fried. Ludw. Gustav Simon (1824-76) studied at 
Giessen and Heidelberg, graduating in 1848, and at once entered the 
Hessian army, in which he became medical director in 1861, in the 
same year was appointed to the chair of surgery at Rostock, and in 
1867 accepted a call to the same position in Heidelberg. His first 
publication was Ueber Schusswunden, etc. (1851), soon after which, on a 
visit to Paris, he became acquainted with Jobert's method of operating 
for vesico-vaginal fistula, and on his return established a small hospital, 
acquired great reputation as an operator for such aifections, and published 
a number of papers on the surgery of the female genitals. After going 
to Heidelberg he performed the first operation for nephrectomy in 1869, 
and published his Ohirurgie der Niercn in 1871, the second part appear- 
ing after his death, in 1876. He was a bold and skilful surgeon, and 
made numerous improvements in methods of investigating and treating 
surgical affections. He was also a voluminous writer, but his publica- 
tions were concise monographs, and not large, systematic treatises. 

Adolf Georg Jacob von Thaden, a native of Holstein, studied in 
Heidelberg and Kiel, graduating in 1853, after which he was for two 
years an assistant of Esmarch, and in 1861 became surgeon of the new 
city hospital at Altona. He was a skilful, scientific surgeon. 

George Albert Liicke (1827-94), a native of Magdeburg, studied at 
Heidelberg, Halle, and Gottingen. He became assistant to Blasius at 
Halle in 1854, and soon after became assistant to von Langenbeck in 
Berlin, and privatdocent. In 1865 he became professor of surgery at 
Berne, and in 1872 accepted the same position at Strasburg, where he 
remained until his death. 

Carl Hueter (1838-82), son of a Avell-known obstetrician of Mar- 
burg, graduated in 1859, after which he studied in Vienna, London, and 
Paris, and became a privatdocent in Berlin and an assistant of Langen- 
beck. In 1868 he succeeded Simon as professor of surgery at Rostock, 
and in 1869 accepted a call to the same chair at Greifswald. Hueter 
was a scientific surgeon, giving great attention to pathology and bacteri- 
ology ; he was also a skilful operator, made many improvements in 
method in resections, tracheotomy, excision of the rectum, etc., and was 
a voluminous writer. His principal works are — Kiinik der Gelenk- 
krankheiten (1870-71 ; 2d ed. 1876-78), Die cdlgemeine Chirurgie (1873), 
and Grundriss der Chirurgie (1880-82). 



126 THE HISTORY AND LITERATURE OF SURGERY. 

Hermann Maas (1842-86) graduated at Breslau in 1866, and became 
assistant to Middeldorpf, and privatdocent, and in 1877 professor of sur- 
gery at Freiberg. His chief work was his Kriegschirurgische Bdtrdge 
aus dem Jahre 1866 (published in 1870). 

Heinrich Wilh. Franz Leisrink (1845-85) studied in Gottingen and 
Kiel, graduating in 1868, and settled in Hamburg, where he became 
distinguished as a surgeon and contributed some valuable papers to 
periodicals. His most important work was Die moderne Radikal- 
Operaiion der TJnterleibsbruche, eine statistische Arbeit (1885). 

Paul Fried. Immanuel Vogt (1849-85) studied at Greifswald, grad- 
uating in 1865, and in 1882 succeeded Hueter as professor of surgery. 
His principal works were — Die ohirurgisehen Krankheiten der oberen 
Extremitdten (1881) and Mittheilungen aus der Chirurgischen Klinik in 
Greifswald (1884). 

Eichard von Volkmann (1830-89), son of Alfred Wilhelm Volk- 
mann, professor of anatomy and physiology in the University of Halle, 
was educated at Halle, Giessen, and Berlin, and obtained his medical 
degree in 1854. He was an assistant in the surgical clinic of Professor 
Blasius, in 1857 became privatdocent, and in 1867 professor of surgery 
at Halle. With Langenbeck and Simon he founded the German Sur- 
gical Association, and in 1874 said before this society: "There is no 
such thing as luck in surgery : for every case of pyaemia, erysipelas, and 
necrosis after amputation the surgeon who treats it must be held respon- 
sible." His contributions to surgery and to surgical literature were 
numerous and important, and he was the first German carefully to study 
Lister's methods and to urge their adoption upon German surgeons. 
Volkmann was a poet as well as a surgeon, but issued his poems under 
another name, and few persons know that Richard Leander, the German 
poet, is the same person as Richard Volkmann, the famous surgeon of 
Halle. 

Theodor Billroth (1829-94), a native of Bergen on the island of 
Rugen, studied at Greifswald, Gottingen, and Berlin, graduating at the 
latter university in 1852. He became assistant to von Langenbeck, 
privatdocent in 1856, professor of clinical surgery at Zurich ia 1860, 
and professor of surgery in the University of Vienna in 1867, succeed- 
ing Franz Schuh. During the last twenty-five years he has been one 
of the most celebrated surgeons in the world as an investigator in surgi- 
cal pathology, a bold and successful operator, a voluminous writer, and 
a clinical teacher. He first excised the larynx for cancer in 1873, first 
successfully excised a large portion of the stomach in 1881, and gave 
a strong impetus to the progress of operative surgery of the intestinal 
tract. His lectures on surgical pathology and therapeutics have passed 
through many editions and translations ; his reports on clinical surgery 
were translated into English in 1881, and the total number of his pub- 
lished books and papers was about one hundred and forty. 

The history of surgery in Denmark is merely the old story of the 
barbers and barber surgeons until near the end of the eighteenth century. 
The University of Copenhagen was founded in 1479, and possessed a 
nominal medical faculty consisting of two or three physicians who read 
the works of Galen and Avicenna. In 1559 some attempt was made to 
introduce anatomical studies, and the young physicians had to travel in 



THE HISTORY AND LITERATURE OF SURGERY. 127 

foreign countries before completing their studies and obtaining their 
degree. In 1577, Frederick II. issued statutes for the Collegium Chi- 
rurgicum of Copenhagen, in which it was ordered, seeing that from 
ancient time there had been only six barbers in the city — i. e. barber 
surgeons — that the term of apprenticeship should be three years, and then 
the apprentice was to travel in foreign countries for four consecutive 
years. Travelling lithotomists had to obtain the approval of the cor- 
poration before they were allowed to operate. Controversies between 
the physicians and the barbers occurred as a matter of course. In 1736, 
Simon Krueger (1687-1760), a barber surgeon, with others, founded the 
" Theatrum Anatomico-chirurgicum," a school for teaching anatomy and 
surgery, which prospered for the next twenty-four years, but was sup- 
pressed in 1772. In 1783 the Academia Chirurgica was created. 
Krueger was an excellent teacher, but wrote very little. 

Heinrich von Moinichen, a surgeon of Copenhagen, published in 
1665 his Observationes Medico-chirurgicce, of which there were three 
later editions. 

Georg Heuermann (1722-68), professor of medicine in the Uni- 
versity of Copenhagen, published in 1754-57 his Abhandlung der 
vornehmsten ohirurgischen Operationen am mensohlichen Korper, a well- 
arranged and illustrated work. 

Alexander K. Koelpin (1731-1801) graduated in 1763, after which 
he studied under Hunter in London and Le Cat in Rouen, and returned 
to Copenhagen and became chief surgeon of the Friedrichs Hospital in 
1766. In 1785 he became professor of the newly-organized surgical 
academy. 

Henry Callisen (1740-1824), a native of Holstein and a pupil of 
Simon Krueger, passed his preliminary examination in 1767, after which 
he studied at Paris and under William Hunter in London. Returning 
to Copenhagen, he became chief surgeon of marines, and took his degree 
as doctor in 1772, and in 1773 succeeded Burger as professor of surgery. 
His Institutiones chirurgioce hodiernce (1777) and his Systema chirurgice 
hodierncB, etc. (1778) passed through several editions and translations, 
and were popular text-books until the beginning of the nineteenth 
century. 

Adolf Carl Peter Callisen (1787-1866), a nephew of Henry Callisen, 
graduated at Kiel in 1809, and became a professor in the Surgical 
Academy in Copenhagen in 1817. In 1842 he was professor of sur- 
gery in the university. His best-known work is his Medicinisches 
Sch'iftsteller- Lexicon der jetzt lebenden Aerzte, etc. (in 33 vols. 8vo, 
1830-45). 

The first distinguished surgeon in Sweden was Olaf Acrel (1 717-1806), 
who was chief surgeon of the Seraphim Hospital in Stockholm after its 
foundation in 1752. He became professor of surgery in 1755, and his 
teachings had great influence in the development of surgery in Sweden. 
His principal work is Kirurgisha Handelser (Stockholm, 1759), which 
was translated into Dutch in 1771, and into German in 1772 and 1777. 

Peter af Bjerkin (1755-1818), a pupil of John Hunter and a sur- 
geon in the Finnish army, became chief surgeon of Stockholm in 1809. 
He was the greatest Swedish surgeon in the early part of this century, 
but wrote nothing of importance. 



128 THE HISTORY AND LITERATURE OF SURGERY. 

The first professor of surgery and obstetrics at the University of 
Christiania was Magnus Andreas Thulstrup (1769-1844), a native of 
Copenhagen, who entered the Norwegian military medical service, became 
surgeon-general, and in 1814 professor. He wrote very little. 

Jacob Christian Johan Henrik Gundelach Moeller (1797-1845), a 
native of Jutland, studied in Copenhagen, and in 1842 became professor 
of surgery, and was a distinguished clinical teacher. 

Joh. August Liborius (1802-1870), a surgeon of Gothenburg, was 
well known in his day as a skilled practitioner, and wrote on the starched 
bandage, on hemorrhoids, and on herniotomy. 

The leading surgeon of Sweden in recent years was Carl Gustav 
Santesson (1819-86), a native of Gothenburg, who graduated at Upsala 
in 1846, and became professor of surgery in the Stockholm school in 
1849, retiring in 1885. He contributed a number of papers to the 
journals, and published 07n hoftleden och ledhrbsken uti anatomiskt 
pathologiskt och chirurgiskt hdnseende, etc. (Stockholm, 1849). He was 
a skilled surgeon, a great teacher, and an accomplished gentleman. 

There is little to be said of the history of surgery in Russia prior to 
the middle of the nineteenth century. The priests were the physicians 
for the great mass of the people, but a few medical men were brought 
from other countries during the sixteenth, seventeenth, and eighteenth 
centuries for the service of the court. Among these was Bidloo, who 
induced Peter I. to found a medico-chirurgical college and hospital in 
the early part of the eighteenth century. In 1768, Simon Zybelin was 
professor of anatomy and surgery in the University of Moscow, and in 
1812, Andreas Sydoratzky (1788—1815) was a teacher of surgery in the 
same university, but no record of their work is accessible. 

Leo Nagumowitsch (1792-1815), an army surgeon, published, in 
Russian, in 1832, a handbook on the treatment of gunshot wounds, and 
Joseph Czekierski (1777-1826), a surgeon of Warsaw and professor of 
surgery in the medical faculty created in 1809, pviblished a manual of 
surgery (4 vols., 1817-18). 

Elias Bujalski (1789-1864), anatomist in the Military Medico-chirur- 
gical School at St. Petersburg, published his Tabulae anatomico-chirur- 
gicae in 1828 and again in 1852. 

Christian Salomon, professor of surgery at St. Petersburg, published 
his handbook of operative surgery in Russian, in two volumes, in 1840. 

The first distinguished Russian surgeon was Mkolaus Iwanowitsch 
Pirogoff (1810-81), who studied at Moscow and Dorpat and obtained 
his degree in 1832, after which he studied in Berlin and Gottingen for 
two years. On his return he gave lectures on surgery at Dorpat, being 
the first Russian professor there. After five years in Dorpat, in 1840, 
he was appointed professor of surgery in the Medico-chirurgical Academy 
of St. Petersburg. His attempts to improve the sanitary condition of 
the military hospital connected with the academy created much ill-feel- 
ing, and for a time he was considered and treated as insane. During 
the Crimean War he was active at Sevastopol, and incurred ill-will by 
his denunciation of the abuses connected with the Russian military 
administration during the siege, the result of which was that he was 
compelled to resign his professorship in the academy at St. Petersburg. 
His contributions to surgery were numerous in relation to gunshot 



THE HISTORY AND LITERATURE OF SURGERY. 129 

wounds, amputatrons, and the surgery of bones, and his name is con- 
nected with a method of osteoplastic amputation through the foot devised 
by him in 1854. The list of his publications is a long one, the most 
important being his Reeherohes pratiques et physiologiqucs sur VMherisa- 
tion (1847) ; Rapport midieal d'un voyage au Caucase, contenant la 
statistique comparative des amputations, etc. (1849) ; Anatomc topographica 
sectionibus per corpus humanum congelatimi, etc. (foL, 1852-59); Chirtir- 
gische Anatomic der Arterien-staemme und Faseien (1861) ; and Grund- 
zuge der allgemelaen Kriegschirurgie (1864). 

Little is known of the Russian surgeons who wrote only in Russian, 
for very few of their works have been considered worth translating. 

Ivan Rklizky (1805-61), professor of clinical surgery at St. Peters- 
burg, in 1847 published a treatise on operative surgery in Russian, of 
which there were two later editions. 

Peter Dubovizki (1815-67), professor of surgery at Kasan, in 1837 
published a treatise on hemorrhage, and one on lithotripsy in 1838. 

Sablozky-Desjatovski (1816-82), professor of surgery at the Medical 
Academy of St. Petersburg in 1842, wrote on hernia, diseases of the 
testicle, and venereal diseases. 

Polycarp Girsztowt (1827-77) studied in St. Petersburg, was an army 
surgeon in the Crimea in 1853-56, and became professor of surgery in 
Warsaw in 1860. He contributed to periodical literature, but wrote no 
special work of any importance. 

Hippolyt Korzeniowski (1827-79) studied at St. Petersburg, became 
professor of surgery in Warsaw in 1868, and professor of surgery in St. 
Petersburg in 1871. 

Karl Daniel von Haartman (1792-1877) was professor of surgery 
and obstetrics in the University of Helsingfors from its foundation in 
1833. He published Casus chirurgici in 1815. 

One of the most distinguished and best known of modern Russian 
surgeons was Julius Szymanowsky (1829-68), a native of Riga, who 
studied at Dorpat, graduating in 1856. In 1858 he went to Helsingfors 
as assistant professor of surgery, and in 1861 accepted a call to Kiew, 
where he acquired a great reputation. He was a skilful operator and an 
excellent teacher. His principal publications are Der Gypsverband mit 
besonderer Rerucksichtigung der Militdrchirurgie (1857) and a treatise on 
operative surgery in Russian (1864-65), of which the first part was 
translated into German and published in 1872. 

Carl Reyher (1846-90), a native of Riga, studied at Dorpat, gradu- 
ating in 1871, became an assistant of von Bergmann, and privatdocent, 
entered the Russian army medical service, and became a distinguished 
surgeon and teacher in St. Petersburg. His principal publications 
relate to antiseptic methods, diseases of the joints, laryngotomy, and 
gunshot wounds. 

Upon the establishment of the Spanish rule in Mexico the medical 
system of Spain was established with it, including the barbers and the 
barber surgeons. The first provision for the examination of physicians 
and surgeons appears to have been made in 1646, being a board com- 
posed of three persons, two of whom were physicians connected with 
the university. From this date to 1700 it is reported that forty-seven 
physicians, one surgeon, three apothecaries, and eighteen barbers were 

Vol. I.— 9 



130 THE HISTORY AND LITERATURE OF SURGERY. 

examined and authorized to practise. Evidently the barbers had the 
greater part of the surgical practice. In 1742 it was ordered that no 
surgeon should undertake to practise medicine nor to give purgatives or 
emetics or diaphoretics or other drugs, and that no apothecary should 
put up prescriptions of a surgeon for such drugs. In short, it is the 
old story of an attempt by the physicians to suppress the surgeons. In 

1719 it was ordered that in the examination of the surgeons no one 
should be approved who had not seen some practice in hospitals, and in 

1720 all the practitioners of medicine, surgery, anatomy, and algebra 
were notified of the necessity of passing this examination. (By " algebra " 
here is meant "bone-setting.") (See "Historia de la Medicina de 
1646-1700," by Dr. Reyes, Gaceta Iledica de Mexico, 1865-66.) 

For a long time after the first settlements on the Atlantic coast of 
North America very few educated physicians were among the immi- 
grants. The clergy included many men of learning, talents, and piety, 
and some distinguished lawyers accepted offices in the neAv colonies, but 
there was little attraction for skilled physicians. Some of the so-called 
"ship surgeons" remained, having commenced by practising on shore 
while their vessels were in port. The following extract from the Dutch 
records, dated February 2, 1652, contains a notice of these barber sur- 
geons : 

" On the petition of the Chirurgeons of New Amsterdam, that none 
but they alone be allowed to shave ; the Director and Council understand 
that shaving doth not appertain exclusively to chirurgery, but is an 
appendix thereunto ; that no man can be prevented operating on himself, 
nor to do another this friendly act, provided it be through courtesy and 
not for gain, which is hereby forbidden." It was then further Ordered, 
that ship-barbers shall not be allowed to dress any wounds, nor admin- 
ister any potions on shore, without the previous knowledge and special 
consent of the petitioners, or at least of Doctor La Montague. 

In 1662 an act regulating chirurgeons' accounts was passed in Virginia 
{Hen. Stat. Va., vol. ii. p. 109). 

At a somewhat later period in Connecticut the popular feeling seems 
to have been rather in favor of ignorance in a medical man, if we mav 
judge from the fact that in 1766 the physicians of Litchfield county, 
having endeavored to form a medical association and having applied for 
a charter for that purpose, were refused by the General Assembly on the 
ground that it would form a monopoly, and that as to quacks and ignorant 
men it was shown that they never administered any physic without the 
prayers of the minister (which cannot be said of the educated physicians), 
and that no medicine can be serviceable without the blessing of God. 
(See Peters' General History of Coimecficuf.) 

In the early days of New England medicine was in its primitive 
stage, being in the hands of the clergy. The earliest practitioners or 
writers on medical subjects were clergymen, many of whom had regu- 
larly studied medicine in order to fit themselves for the duties of their 
new field, just as some of those intending to be missionaries do at 
the present day. For example, Charles Chauncy, the second president 
of Harvard College, graduated in both divinity and medicine at Cam- 
bridge, and is said to have been of the opinion that there ought to be no 
distinction between them, educating his six sons in both professions. 



THE HISTORY AND LITERATURE OF SURGERY. 131 

The first printed document relating to medicine issued in New Eng- 
land is by a clergyman, Thomas Thatcher, who came to this country in 
1685. It is a broadside sheet or poster headed "Brief Eule to Guide 
the Common People of New England How to Order Themselves and 
Theirs in the Small Pocks or Measels." This is usually said to be the 
first medical work published in America, but several were printed in 
Mexico during the sixteenth century, as, for example, Alphonso Lopez 
de Hinojoso summa y recopllacion de cirugia con un arte para saiu/rar 
y examen de Barberos : Va anadido en esta seounda editlonc, el origin y 
naeimiento de las reumas [etc.]. (Mexici, 1595, 4to.) 

The first methodical attempt at the regulation of practice appears 
to have been made by Virginia in 1736 in an act regulating fees and 
the accounts for the practice of physic. This fixed the fee for the ordi- 
nary surgeons or apothecaries at five shillings a visit within five miles, 
and ten shillings within ten miles, but those persons who have studied 
physic in any university and taken a degree therein are allowed double 
these rates. 

In 1760 an act was passed by the city of New York forbidding any 
one to practise as a physician or surgeon in said city until he should have 
been examined and approved by a board composed of " one of his Maj- 
esty's council, a judge of the supreme court, the attorney-general, and 
the mayor," who may call in to their assistance such j^erson or persons 
as they think fit. A similar law was passed in New Jersey in 1772, the 
examiners being any two of the judges of the supreme court. In Mary- 
land, the District of Columbia, and South Carolina the business of exam- 
ination and licensing was placed in the hands of the medical societies. 
The distinction between physician and surgeon soon disappeared, and 
there is no trace of separate organizations for these two classes of prac- 
titioners. 

The majority of the regularly educated physicians in this country in 
1776 were graduates of the University of Edinburgh, the first American- 
born graduate of that school having been John Moultrie of South Caro- 
lina, who obtained his degree in 1749. The first dissection of the human 
body in this country was made in New York by Drs. Bard and Middle- 
ton in 1750. In 1756 a course of lectures on anatomy and surgery, with 
demonstrations on the dead body, was given at Newport, Rhode Island, 
by Dr. William Hunter, a cousin of John Hunter and an Edinburgh 
graduate. The first regularly organized medical school was established 
in Philadelphia by Drs. William Shippen and John Morgan, both 
natives of Philadelphia and graduates of Edinburgh ; Dr. Shippen lec- 
tured on anatomy and surgery. 

The only surgical work by an American author printed in the United 
States prior to 1800 was the Plain, Concise Practical Remnrhs on the 
Treatment of Wounds and Fractures, by Dr. John Jones (New York, 
1775), reprinted at Philadelphia in the following year with Van Swieten 
on The Diseases Incident to Armies and Gunshot Wouiids, the whole 
forming a small volume which was -the manual of the American army 
surgeons during the Revolutionary War.- 

Dr. John Jones (1729-91), a native of New York, studied in London 
under Pott, in Paris under Petit and Le Dran, and in Edinburgh under 
Monro, was surgeon with troops in the French Colonial War of 1758, 



132 THE HISTORY AND LITERATURE OF SURGERY. 

and professor of surgery in King's (now Columbia) College from its 
commencement in 1767. He is said to have performed the first opera- 
tion of lithotomy in this country. His book, above referred to, is, in 
the main, a compend of the teachings of Pott and Le Dran, but contains 
a few original observations, the most remarkable of which is a case of 
trephining in delirium occurring eighty days after an apparently slight 
injury of the head. There was no fracture. After perforating the bone 
he opened the dura mater, but found nothing, and the result was prompt 
recovery. At the beginning of the nineteenth century the leading sur- 
geons in the United States were the two Warrens in Boston, Physick in 
Philadelphia, and Wright Post in New York. 

John Warren (1753-1815) was the first professor of anatomy and 
surgery in the Medical School of Harvard University, which opened in 
1783, being the first medical school in New England. He amputated at 
the shoulder-joint in 1781, extirpated the parotid gland in 1804, and had 
a great reputation as an operator and teacher, but wrote only a few 
addresses and journal articles. 

His son. Dr. John Collins Warren (1778-1856), studied in London, 
Edinburgh, and Paris, and returned and joined his father in practice in 
1802, becoming adjunct professor in anatomy and surgery in 1806, and 
professor in 1815. He was a skilful operator, and introduced several 
new operations, such as excision of the hyoid bone in 1804 and excision 
of the elbow in 1834. In 1837 he published his Surgical observations 
on tumors, chiefly a collection of cases observed and treated by him — 
an important work for reference. He was practically the introducer 
of anaesthesia in surgical operations. 

Phihp Syng Physick (1768-1837), called by some the "Father of 
American Surgery," a native of Philadelphia, a pupil and personal friend 
of John Hunter, who refers to him in his treatise on the blood as hav- 
ing performed many of the experiments referred to, took his medical 
degree at Edinburgh in 1792, became surgeon of the Pennsylvania 
Hospital in 1794, and was appointed in 1805 to the chair of surgery 
established in the University of Pennsylvania in that year. His con- 
tributions to practical surgery were numerous, but he wrote nothing, 
and his views are, for the most part, known through the treatise of his 
nephew. Dr. Dorsey. Among these contributions may be mentioned 
the lengthening of Desault's splint for fracture of the femur, which 
reached only to the crest of the ilium, making it extend from the axilla 
to below the foot ; the internal division of stricture of the urethra ; the 
use of the seton in ununited fracture ; his operation for the cure of 
preternatural anus ; and the washing out of the stomach by means of a 
gum-elastic catheter and a syringe in a case of poisoning. 

The first lectures on surgery in Philadelphia were given by Dr. 
William Shippen (1733-1808), a native of Philadelphia, who studied in 
Leyden, Edinburgh, and London, and was a special pupil of William 
Hunter. In 1762 he gave a course of private lectures on anatomy and 
surgery in Philadelphia, and in 1765 became professor of anatomy and 
surgery in the Medical Department of the University of Pennsylvania, 
just established. 

Wright Post (1766-1822), a native of New York, studied in London 
in 1784-86 under Mr. Sheldon, and was appointed professor of surgery 



THE HISTORY AND LITEEATURE OF SUBOEJRY. 133 

in Columbia College in 1792. He, first in this country, performed the 
Hunterian operation for aneurism of the femoral in 1796, ligated the 
subclavian on the outer side of the scaleni in 1817, and in 1813 success- 
fully ligated the external iliac, this being the second operation of this 
kind. He was a skilled anatomist and a good teacher, but he wrote 
nothing beyond a few accounts of cases. 

The first systematic treatise on surgery published by an American 
author was the Elements of surgery of Dr. Dorsey (Philadelphia, 2 vols. 
8vo, 1813), of which a second edition appeared in 1818, and a third in 
1823. 

John Syng Dorsey (1783-1818), a native of Philadelphia, studied 
under his uncle, Dr. Physick, and afterward in London and Paris, and 
in 1807 became adjunct professor of surgery in the University of Penn- 
sylvania. His book was a popular text-book ; its chief value is due to 
the fact that it contains so much of the experience of Dr. Physick. In 
1811 Dorsey successfully ligated the external iliac for inguinal aneurism, 
this being the first case of that operation in the United States. 

In 1819, Dr. Physick resigned as professor of surgery to become 
professor of anatomv, the chair of surgery being filled by Dr. Gibson. 
Dr. William Gibson (1788-1868) was born in Baltimore, Md. He 
studied in Edinburgh, where he graduated in 1809, was a pupil of John 
Bell, and, after his graduation, of Sir Charles Bell in London ; professor 
of surgery in the University of Maryland in 1812, and professor of 
surgery in the University of Pennsylvania from 1819 to 1855, when he 
resigned. In 1824 he published his Tnxtihdes and pradke of surgery, 
M'hich became a popular text-book, the eighth edition having appeared 
in 1850. He was the first to perform the operation of ligation of the 
common iliac, which he did in 1812, and successfully to repeat the 
Ctesarean section on the same patient, which he did in 1837. His 
reports on rupture of the axillary artery in attempts to reduce old dis- 
locations of the head of the humerus contributed greatly to his repu- 
tation. He formed a large and valuable collection of pathological 
specimens, colored drawings of tumors, etc., some of which are now 
in the Army Medical Museum at Washington. 

The surgeon of the first part of this century whose name is now best 
known to fame was Dr. Ephraim McDowell (1771-1830), a native of 
Virginia, who studied in Edinburgh in 1793 under John Bell, who was 
then giving special attention to diseases of the ovaries. In 1795 he 
commenced practice at Danville, Kentucky, and soon became the lead- 
ing physician of the West. In 1809 he performed the first methodical 
excision of the ovary for the cui'e of timior of that organ, and published 
an account of it, and of two other similar cases, in the Eclectic Repertory 
of Philadelphia in 1817. His reports of the operation attracted little 
attention at the time, and the few published comments on them were 
mostly expressions of doubt as to the accuracy of his statements ; but 
the paper of Mr. Lizars, " Observations on the extirpation of the ova- 
ria," in the Edinburgh Medical and Surgical Journal in 1824, made them 
generally known, and although it was long after that date before ova- 
riotomy became i-ecognized as a proper surgical operation, yet the credit 
due to McDowell for originating it has never since been seriously dis- 
puted. He wrote very little and very reluctantly, and was not a teacher 



134 THE HISTORY AND LITERATURE OF SURGERY. 

in any school, but his name stands high in the list of the great surgeons 
of America. 

Another distinguished surgeon of this period was Dr. Nathan Smith 
(1762-1829), a native of Massachusetts, who studied in the Harvard Medi- 
cal School, in Edinburgh, and in London, and in 1797 founded a medical 
school in connection with Dartmouth College. In 1813 he became pro- 
fessor of medicine and surgery in Yale College. He was the second 
person to perform ovariotomy in this country, which he did in July, 
1821, without any knowledge of the work of IMcDowell. He performed 
the first amputation at the knee-joint in the United States in 1824, first 
used the trephine in localized inflammation and abscess of the shafts of 
the long bones, and introduced the manipulation method in the treatment 
of dislocations of the hip-joint. He wrote little, but an account of his 
methods and practice is given in a little book entitled Medical and sur- 
gical memoirs, edited by his son, Nathan E,. Smith (published at Balti- 
more in 1831). It contains an excellent paper on necrosis, a description 
of an improved apparatus for the treatment of fractures of the femur, 
remarks on dislocations of the hip, etc. 

Some bold operations were performed in these early days by men 
who wrote nothing and of whom little is known ; for example, abdom- 
inal section for extra-uterine pregnancy in 1759 by John Bard of New 
York, and in 1791 by William Baynham ; the ligation of the common 
carotid in 1803 by Mason Fitch Cogswell, and in 1807 by Dr. Amos 
Twitchell of New Hampshire ; the complete excision of the clavicle in 
1811 by Dr. Charles McCreary of Kentucky ; and the excision of a part 
of the lower jaw by Dr. AVm. H. Deadrick of Tennessee in 1810. In 
1819, Dr. Wm. C. Daniel of Savannah first employed extension by 
means of a weight in the treatment of fracture of the femur, but did 
not publish the method until 1829 (^m. J. Med. Sc, 1829, iv. 330). In 
1823, McGill of Maryland successfully ligated both carotids; in 1824, 
Dr. D. L. Rodgers removed nearly the ^vhole of both upper jaws. 

Between 1820 and 1850 the prominent surgeons in the large cities 
were John C. Warren and George Hayward in Boston ; Valentine 
Mott, J. Kearny Rodgers, Willard Parker, Alfred C. Post, and John 
Watson in New York ; W. Gibson (above referred to), J. R. Barton, 
George McClellan, George W. Norris, and Thomas D. Mutter in Phila- 
delphia ; Nathan R. Smith in Baltimore ; R. D. Mussey in Cincinnati ; 
and Daniel Brainard in Chicago. 

Valentine Mott (1785-1865), a native of Long Island, the son of a 
physician, studied medicine at Columbia College, obtaining his degree 
in 1806. He then went to London, became a pupil of Astley Cooper, 
returned in 1810, and was appointed professor of surgery in Columbia 
College, and in 1813, when this school was merged in the facultv of the 
College of Physicians and Surgeons, he retained the chair of surgery. In 
1826, with the other professors of the College of Physicians and Surgeons, 
he resigned his chair, and then with several of his associates founded the 
Rutgers Medical College ; he took the chair of operative surgery in the 
College of Physicians and Surgeons, which he resigned in 1834 on 
account of his health. In 1840 he was appointed to the professorship 
of surgery in the Medical Department of the University of New York. 
For the next ten years his reputation drew crowds of students from all 



THE HISTORY AND LITERATURE OF SURGERY. 135 

parts of the United States. In 1850 he resigned the chair, making 
another visit to Europe. In the spring of 1852 he was appointed 
emeritus professor of surgery in the Medical Department of tire Uni- 
versity of the City of New York, and from that time until his death 
he delivered an annual course of lectures. 

Mott's first contribution to operative surgery was the ligature of the 
innominate artery in 1818, the patient surviving for a long time, but 
finally dying of secondaiy hemorrhage. The case established the prac- 
ticability, and the propriety in certain cases, of the operation. It \\'as 
finally successfully performed by Dr. A. W. Smythe of New Orleans in 
1864, in which case repeated hemorrhages also occurred, and the verte- 
bral artery was ligated fifty-four days after the first operation. Mott first 
applied a ligature to the primitive iliac in 1827 ; in 1828 he entirely 
removed the clavicle for osteosarcoma; in 1812 he made an original 
operation for the relief of ankylosis of the lower jaw. At the time 
when, in 1821, he excised the right half of the lower jaw in a case of 
tumor he was not aware that a similar operation had been performed in 
1810 by Dr. W. H. Deadrick of Tennessee, since no history of the 
operation was published until 1828. Dupuytren in 1812 had removed 
a large part of the lower jaw for cancer. Amputation of the hip-joint 
was performed by Dr. Mott in 1824, and it was for some time supposed 
that it was the first operation of the kind in America, but it is now 
known that it was performed by Dr. AA'alter Brashear of Kentucky in 
1806, but no account of his case had ever been published. Speaking 
of his excision of the clavicle. Dr. Mott called it his " Waterloo opera- 
tion," since it was performed on the 17th of June, the day before the 
anniversary of that battle. In 181.3, Dr. Charles McCrcary had removed 
the right clavicle for disease of the bone, but it was little enlarged, com- 
paratively isolated, and the operation was a very simple one, being 
entirely diiferent from the extremely difficult operation performed by 
Dr. Mott. The patient rapidly recovered. Besides the innominate 
artery, he tied the subclavian eight times, the primitive carotid fifty-one 
times, the carotid twice, the common iliac once, the external iliac six 
times, the internal iliac twice, the femoral fifty-seven times, and the 
popliteal ten times. His writings consist mainly of reports of cases 
and operations for periodicals. 

J. Kearny Rodgers (1793-1851), a native of New York, was a pupil 
of Dr. Wright Post and graduated at the College of Physicians and 
Surgeons in 1816. He studied in London under Astley Cooper, became 
surgeon of the New York Hospital in 1822, and tied the left subclavian 
artery within the scaleni for aneurism in 1845, the first time this opera- 
tion had been performed : it was unsuccessful. The first successful 
operation of this kind was by Dr. Halsted of Baltimore in 1892. Dr. 
Rodgers successfully wired an ununited fracture of the humerus in 1827 
after excision had been unsuccessfully performed, perhaps the first ope- 
ration of this kind, and made a cuneiform osteotomy in ankylosis of the 
hip in 1840. He wrote only a few papers for periodicals. 

Willard Parker (1800-84), a native of New Hampshire, studied 
under John C. Warren, and graduated at Harvard in 1830. He was 
for a short time professor of surgery in Berkshire Medical College, and 
was a colleague of Gross in Cincinnati. In 1839 he became professor 



136 THE HISTORY AND LITERATURE OF SURGERY. 

of surgery in the College of Physicians and Surgeons, surgeon of 
Bellevue Hospital in 1845, and surgeon of the New York Plospital in 
1856. He was an excellent teacher and operator and greatly beloved 
by his pupils, who constituted his best contributions to surgery. He 
was the first operator for strabismus in this country. 

Alfred C. Post (1805-86), a native of New York and a nephew of 
Dr. Wright Post, graduated in medicine at the College of Physicians 
and Surgeons in New York in 1827, and continued his studies in Paris, 
Berlin, and Edinburgh. He was one of the founders of the Medical 
Department of the University of the City of New York in 1851, in 
which he was professor of surgery and pathological anatomy. He 
wrote no systematic treatise, but contributed numerous cases to the 
journals, and was specially skilled in plastic surgery. 

John Watson (1807-63), a native of Ireland, came with his pa- 
rents to America in 1810, and graduated in 1832. He became sur- 
geon of the New York Hospital in 1838, where he first introduced 
regular clinical instruction in surgery, though Dr. Alexander H. Stevens 
had previously delivered occasional clinical lectures. He contributed 
many cases to journals, but wrote no systematic treatises. He collected 
what was at that time the most valuable private medical library in this 
country, the greater part of which, after his death, was left to the New 
York Hospital Library. 

John Rhea Barton (1794-1871), a native of Lancaster, Pa., grad- 
uated at the University of Pennsylvania in 1818, and became surgeon 
of the Pennsylvania Hospital. His name is associated with a form of 
fracture of the lower end of the radius, with a special form of bandage 
for fracture of the jaw, and with osteotomy for ankylosis, which he 
first performed in 1826. In 1834 he wired a fractured patella. 

George McClellan (1796-1847) was a native of Connecticut and a 
pupil of Dr. Dorsey, graduating at the University of Pennsylvania in 
1819. He founded the Jefferson Medical College in 1824, in which he 
was professor of surgery until 1838. He excised the body of the lower 
jaw in 1823, excised the parotid gland for tumors, and was a bold and 
showy operator. After his death his book on Principles and practice of 
surgery was published in 1848 : it is noteworthy only for the very 
excellent description of shock which it contains. 

George Washington Norris (1808-75) was a native of Philadelphia, 
and graduated at the University of Pennsylvania in 1830. After two 
years' service in the Pennsylvania Hospital he went to Paris, and stud- 
ied under Dupuytren, Yelpeau, and Roux. He became surgeon to the 
Pennsylvania Hospital and professor of clinical surgery in the Uni- 
versity of Pennsylvania. His name is well known in medical literature 
from the extremely valuable statistical contributions to practical surgery 
which he published in the American Journal of the Medical Sciences be- 
tween 1828 and 1854. They rank among the best work of this kind 
which has ever been done in any country, and his results are quoted in 
all subsequent treatises upon the subjects upon which he wrote. 

Thomas Dent Miitter (1811-59), a native of Virginia, graduated at 
the University of Pennsylvania, after which he studied medicine in 
Paris. He became professor of medicine in the Jefferson Medical Col- 
lege in 1841, and is celebrated for his plastic operations for the cure of 



THE HISTORY AND LITERATURE OF SURGERY. 137 

deformities resulting from burns. He gave his museum to the College 
of Physicians of Philadelphia, with thirty thousand dollars for its main- 
tenance and the endowment of a lectureship. In this connection may be 
mentioned : 

AYilliam E. Horner (1793-1853), a native of Virginia, who became 
a surgeon in the hospital department of the army in 1813, when he was 
twenty years old and before he had graduated. He became professor of 
anatomy in the University of Pennsylvania in 1831, succeeding Dr. 
Dorsey. His name is connected with the Wistar and Horner Museum, 
which he bequeathed to the university, and also with the muscle which 
he named the " tensor tarsi." His contributions to surgery are to be 
found in papers in the American Journal of the Medical Sciences. 

R. D. Mussey (1780-1866), a native of New Hampshire, studied 
medicine under Dr. Nathan Smith, and graduated at the University of 
Pennsylvania in 1809. He was professor of the theory and practice of 
medicine at Dartmouth, 1814; professor of anatomy and surgery in the 
same school, 1819 ; professor of surgery in the Medical College of Ohio 
at Cincinnati in 1838 ; and professor of surgery in the Miami Medical 
College in Cincinnati in 1852. He was a bold operator, and first tied 
both carotid arteries in 1827 for a large bleeding tumor of the head, and 
removed the scapula and clavicle for tumor following amputation at the 
shoulder-joint. His only contributions to surgical literature were in the 
shape of reports of cases in the journals. 

Daniel Brainard (1812-66), a native of Western New York, graduated 
at the Jefferson Medical College, Philadelphia, in 1834. He successfully 
amputated at the hip-joint in Chicago in 1838, which established his 
reputation, and in 1854 published an excellent essay on the treatment 
of ununited fractures. He was the founder of Rush Medical College. 

One of the most celebrated surgeons of the West of this jseriod was 
Benjamin W. Dudley (1785-1870), a native of Virginia, who graduated 
at the University of Pennsylvania in 1806, after which he studied in 
Paris and London, returning to Lexington in 1814, and became pro- 
fessor of anatomy and surgery in the Medical Department of the 
Transylvania University in 1817. His reputation rested mainly upon 
his operations for lithotomy, which he performed two hundred and 
twenty-five times with almost unparalleled success. He wrote nothing 
except a few short essays, the first of which, Observations on injuries of 
the head [including cases of trephining for epilepsy], was published in 
the first number of the Transylvania. Journal of Medicine in 1828, and 
is a very important paper in the history of this operation. 

We now come to an epoch in the history of surgery. On November 
3, 1846, Dr. Henry J. Bigelow read before the American Academy of 
Arts and Sciences an abstract of a paper which was published in full in 
the Boston Medic(d and Sutr/ical Journal of November 18, 1846, under 
the title " Insensibility during surgical operations produced by inhala- 
tion," which was the first definite account of the method of produc- 
tion of satisfactory anaesthesia in surgical operations. Writers of the 
thirteenth and fourteenth centuries had described the inlialation of nar- 
cotic vapors from certain plants for this purpose. Sir Humphry Davy 
had suggested in 1800 that "nitrous oxide may probably be used with 
advantage in surgical operations." Mr. Hickman, a London surgeon, 



138 THE HISTORY AND LITERATURE OF SURGERY. 

had written in 1828 a letter to King Charles X. (which letter was laid 
before the Academy of Medicine of Paris), in Avhich he said that he had 
discovered the means of performing the most troublesome operations 
without pain by producing insensibility by the introduction of certain 
gases into the lungs {Archiv. y'en. de mkl., 1st ser. xviii. p. 453). Dr. 
Crawford W. Long of Athens, Ga., had produced anaesthesia by ether 
in 1842 for the operation of removing small tumors, but had not pub- 
lished the results, when Dr. "Warren allowed a dentist. Dr. Morton, to 
give ether to produce insensibility while he performed a small opera- 
tion in the Massachusetts General Hospital. 

It is to Warren, Hayward, and Bigelow that the surgical world is 
indebted mainly for a sufficient, general, and safe method of ansesthesia. 
Morton wanted to patent his method, which was not a thoroughly safe 
one until modified by Bigelow, and little credit is due to him or to Wells 
or Jackson for the part which they then played in the business. The 
statements of Dr. Bigelow were readily accepted by surgeons, and early 
in 1847 ansesthesia was in general use throughout the civilized world. 

Nothing like it had been known before, and there has been little 
improvement in it since, for chloroform, though more convenient for 
use, is decidedly more dangerous than ether in many cases. Most of the 
great operations had been devised and performed by a few skilled opera- 
tors before the introduction of anaesthesia, but the performance was not in 
the deliberate, careful manner which is now well recognized as charac- 
terizing the best surgery, especially in these days of asepsis and anti- 
sepsis. The influence of ansesthesia upon surgical diagnosis has been 
almost as great as upon methods of operation, for with its aid it is possible 
to explore the interior of the body in ways that would be impossible with- 
out it. AVith its aid the recent graduate undertakes operations which he 
would not dream of trying without it : it has done away with the need for 
some of the most special qualifications which formerly were thought to be, 
if not indispensable, at least of great importance to the operator. 

Henry Jacob Bigelow (1816-90), a native of Boston, took his medi- 
cal degree in 1841, after which he spent three years in Europe, most of 
the time in Paris. In 1845 he was appointed instructor of surgery at 
the Tremont Street INIedical School. In 1846 he was made surgeon to 
the Massachusetts General Hospital, and in 1849 was appointed profes- 
sor of surgery in the Harvard Medical School, the two chairs of surgery 
and clinical surgery, previously held by Dr. J. C. Warren and Dr. 
George Hayward, being united. He performed the first excision of the 
hip-joint in this country in 1852, and first explained the mechanism of 
the ileo-femoral ligament and its importance in reducing dislocations of 
the hip-joint. His chief contribution to surgery was his operation of 
litholapaxy, which has effected a great change in the treatment of vesical 
calculus. He was a graceful and dexterous operator, a clear and epigram- 
matic teacher, and the leading surgeon in New England until he retired 
in 1882. 

The number of American surgeons who have become known as 
inventors, teachers, or writers since 1850 is very large, and onlv a 
brief notice can be given of the most prominent. In New York we 
have had William H. Van Buren (1819-83), who studied in Paris, Mas 
an assistant surgeon in the army for four years, in 1845 joined Mott in 



THE HISTORY AND LITERATURE OF SUROERY. 139 

clinical teaching, became professor of anatomy in 1852, and professor 
of surgery in the Bellevue Medical College in 1868. His Contributions 
to practical surgery appeared in 1865, and his work on Diseases of the 
genito-iu'inary system in 1874. 

Gurdon Buck (1807-77), surgeon of the New York Hospital in 1837, 
and of St. Luke's in 1858, made valuable contributions to surgery in the 
method of treating fractures of the thigh by weight and pulley, in the 
plastic surgery of the face, and in the treatment of ankylosis of the 
knee. 

James R. Wood (1816-82), the first to introduce clinical teaching in 
Bellevue Hospital, and one of the founders of Bellevue Medical College, 
was a bold operator and a very popular teacher. He removed the entire 
lower jaw in a case of phosphorus-necrosis, leaving the periosteum from 
which a new jaw was formed ; excised Meckel's ganglion with the superior 
maxillary branch of the fifth pair ; and was one of the first in America 
to perform excision of the shoulder- and elbow-joints. 

Frank H. Hamilton (1813-66), a native of Vermont, graduated in 
Philadelphia in 1833; became professor of surgery in Buffalo in 1844, 
and in the Bellevue Medical College in New York in 1862. He pub- 
lished his Practical treatise on fractures and dislocations (Philadelphia, 
1860) and his Practical treatise on military surgery (1861 ; 2d ed. 1865). 

Alden March (1795-1869) settled in Albany in 1820 after gradu- 
ating at Brown University, Rhode Island, and commenced lecturing on 
anatomy in 1821, being the first lecturer in that city. He was professor 
of surgery in the Albany Medical College in 1838, and gave one of the 
first surgical clinics in this country. He made valuable investigations 
in hip-joint disease, and performed a large number of surgical operations, 
including sixty-five amputations through the thigh and eleven excisions 
of the lower jaw. 

Henry Berton Sands (1830-88) graduated from the College of 
Physicians and Surgeons in New York in 1854; studied in Paris; 
and on his return became professor of anatomy, and then of surgery. 
He was surgeon to the Bellevue and New York Hospitals and to the 
Roosevelt Hospital, and in the latter part of his life was the leading 
surgeon in New York City. He was the first to operate in peritonitis 
due to perforation of the appendix. 

Here also may be mentioned J. Marion Sims (1813-83), a native of 
South Carolina, who commenced practice in Montgomery, Alabama, and 
there devised his mode of operating for vesico-vaginal fistula ; he came 
to New York in 1853, and became the founder of modern gynaecology. 

The Philadelphia surgeons of this period who have finished their 
work are Gross (father and son), Agnew, Pancoast, and Smith. 

Samuel D. Gross (1805-84), a native of Pennsylvania and a grad- 
uate of the Jefferson Medical College in 1828, after filling various 
chairs in Western schools and in New York accepted the chair of 
surgery in the Jefferson Medical School in 1865, from -which he retired 
in 1882. He was a man of strong personality and great influence, an 
incessant worker, a voluminous writer, an excellent teacher, and one of 
the most distinguished surgeons of his time. He wrote the first 
systematic treatise on pathological anatomy by an American author, 
made original experiments on wounds of the intestines, published 



140 THE HISTORY AND LITERATURE OF SURGERY. 

valuable monographs on diseases of the bladder (1851 ; 2d ed. 1855), 
on foreign bodies in the air-passages (1854), and a system of surgery in 
two large volumes (1859 ; 6th ed. 1882), which is an important book of 
reference. 

His son, Samuel W. Gross (1837-89), graduated at the Jefferson 
Medical College in 1857. On the outbreak of the Civil War he became 
a surgeon of volunteers, acting as medical director in various departs 
ments until 1865. In 1882, on the retirement of his father, he was 
elected one of the professors of surgery in Jefferson Medical College. 
He made numerous contributions to surgical literature in the journals, 
published a treatise on Tumors of the mammary glands in 1882, a 
treatise on Impotence and sterility in 1881, and assisted his father in the 
preparation of the various editions of his System of Surgery. He was 
a bold yet careful operator and an earnest and eloquent lecturer. 

Joseph Pancoast (1805-82), a native of New Jersey, graduated at 
the University of Pennsylvania in 1828. He began teaching practical 
anatomy and surgery in 1831. In 1838 he was elected professor of 
surgery in the Jefferson Medical College ; in 1847, professor of 
anatomy in the same college. He published his Treatise on operative 
surgery in 1844 (3d ed. 1852). He Avas distinguished for his operations 
in plastic surgery, especially for exstrophy of the bladder ; devised the 
operation of section of the third branch of the fifth pair of nerves at 
its issue from the base of the skull, and of the second branch of the 
fifth pair at the same place ; was a skilled anatomist, a dexterous ope- 
rator, and a popular clinical teacher. 

Henry H. Smith (1815-90), a native of Philadelphia, graduated at 
the University of Pennsylvania in 1837, after which he studied in 
London and Paris. He became professor of surgery in the University 
of Pennsylvania in 1855, and resigned in 1871. His System of opera- 
tive surgery, published in 1853 (2d ed. in 1856), contains a valuable 
history of surgery in the United States, with an index of the principal 
contributions of American writers on subjects connected with operative 
surgery down to the year 1854. 

Francis Fontaine Maury (1840-79), a native of Kentucky, grad- 
uated at Jefferson Medical College in 1862 ; performed the first opera- 
tion of gastrotomy in this country, excision of the brachial plexus for 
painful neuroma, operation for exstrophy of the bladder, and two opera- 
tions for extirpation of the thyroid gland. He was surgeon of the 
Philadelphia Hospital. 

Dr. D. Hayes Agnew (1818-92), a native of Pennsylvania, grad- 
uated at the University of Pennsylvania in 1838. In 1852 he became 
the head of the Philadelphia School of Anatomy, to wliich he soon 
added a school of operative surgery; in 1863 he left this to become 
demonstrator of anatomy in the University of Pennsylvania, in which 
he became professor of clinical surgery in 1878 and professor of surgery 
in 1871. A highly-skilled anatomist, an unusually dexterous operator, 
and a keen, shrewd diagnostician, he acquired an immense practical 
experience in all forms of surgical affections and treatment, which he 
embodied in his treatise on the Principles and practice of surgery, pub- 
lished in three large volumes in 1878-83, and again in a second edition 
in 1889. He was one of the few great surgeons who have continued to 



THE HISTORY AND LITERATURE OF SURGERY. 141 

practise medicine as well as surgery until the end of their career, and 
he did this because he believed it made him a better surgeon. 

J. L. Atlee (1799-1885), a native of Lancaster, Pa., graduated at the 
University of Pennsylvania in 1820, and practised at Lancaster through- 
out his life. In 1843 he revived the operation of ovariotomy, and ^vith 
his brother established it on a firm basis. He was the first successfully to 
remove both ovaries at one operation. 

Washington L. Atlee, his brother (1808-78), was a pupil of George 
McClellan, and performed his first operations for ovariotomy in 1844. 
This operation he performed three hundred and eighty-seven times, and 
had more influence in popularizing it than any other man in this country. 
His most important contribution to literature is on the diagnosis of 
ovarian tumors, published in 1873. He was also celebrated as an ope- 
rator for the removal of uterine tumors. 

Jonathan Knight (1789-1864) studied at the University of Pennsyl- 
vania, and became professor of anatomy and physiology in the Medical 
Institution of Yale College when it was organized in 1813. In 1838 he 
became professor of surgery, and held the chair to the end of his life. 

Paul F. Eve (1806-77), a native of Georgia, graduated from the 
University of Pennsylvania in 1828. He studied several years in 
Europe, was a volunteer surgeon in the Polish Rebellion of 1831, and 
became professor of surgery in the Medical College of Georgia in 1832, 
in Louisville University in 1849, in the Nashville University in 1850, 
in the Missouri Medical College of St. Louis in 1868, and professor of 
operative and clinical surgery in the University of Nashville from 1870 
to the date of his death. He published A collection of remarkable cases 
in surgery (Philadelphia, 1857) — a most useful and interesting work, and 
it is highly desirable that a similar collection should be made for the lat- 
ter half of this century. 

George C. Blackman (1819-71), a native of Connecticut, graduated 
in medicine at the College of Physicians and Surgeons, New York, in 
1 840, and for the next ten or fifteen years was engaged in study in Great 
Britain and in France, and as surgeon of an Atlantic packet-ship ; in 1855 
he became professor of surgery in the Medical College of Ohio. He was a 
skilful diagnostician and anatomist, a bold surgeon, an excellent clinical 
teacher, and thoroughly at home in surgical literature. He contributed 
largely to periodicals, re-edited Mott's edition of Velpeau, and translated 
the work of Vidal on Venereal diseases, but left no monograph or sys- 
tematic treatise. 

Charles Pope (1818-70), professor of surgery in St. Louis, Mo., in 
1847, was distinguished as an operator and teacher, but wrote very 
little. 

Elias Samuel Cooper (1823-62), a native of Ohio, studied medicine in 
Connecticut when very young ; began practice at nineteen years of age, 
soon after which he excised a large portion of the lower jaw, and at the 
age of twenty-three opened a dissecting-room in Peoria, 111., and gave 
lectures on anatomy. In 1855 he removed to San Francisco, and in 
1858 was one of the founders of the Medical Department of the Univer- 
sity of the Pacific, in which he became professor of anatomy and surgery. 
He performed a number of the greater surgical operations, twice ligated 
the innominate artery, twice performed Csesarean section, and repeatedly 



142 THE HISTORY AND LITERATURE OF SURGERY. 

operated for ovarian tumors. One of his most celebrated operationswas 
the removal of a piece of iron an inch long and three-quarters of an inch 
thick, which the explosion of a gun-barrel had driven into the chest 
beneath and behind the heart, and which had remained there over two 
months. His contributions to the literature of surgery are found entirely 
in periodicals. 

Kobert Nelson (1794-1873), a native of Canada, became distinguished 
as a surgeon in Montreal, and especially as a lithotomist ; implicated in 
the rebellion of 1837, he came to the United States, for a short time 
filled the chair of anatomy and surgery at Castleton, Vt., and Pittsfield, 
Mass. ; went to California in 1849, and finally settled in New York. He 
is the author of a pamphlet, Gastrotomy for the removal of non-malig- 
nant tumors from the abdominal cavity (New York, 1864), and of papers 
in the journals, especially in the Northern Lancet, of which he was the 
editor from 1850 to 1856. 

John T. Hodgen (1824-82), a native of Illinois, professor of anatomy 
in the Missouri Medical College in 1852, and professor of clinical and 
military surgery in 1872, made valuable contributions to methods of 
treatment of fractures, and his splint is well known. 

George Alexander Otis (1830-81) was a native of Boston, and gradu- 
ated in medicine at the University of Pennsylvania in 1851. He studied 
in Paris, entered the army in 1861, was curator of the Army Medical 
Museum, and wrote the first two surgical volumes of the Medical and 
surgical history of the war of the rebellion, using the vast material in a 
thoroughly scientific manner. 

Moses Gunn (1822-87), a native of New York, of Scotch descent, 
settled at Ann Arbor, Mich., became professor of anatomy and surgery 
in 1850, and professor of surgery in Rush Medical College in 1867, 
succeeding Brainard. He was a skilled anatomist, a popular teacher, and 
wrote a valuable paper on reduction of dislocations by manipulation. 

John M. Carnochan (1817-87), a native of Savannah, Ga., a pupil of 
Valentine Mott, a surgeon in New York City, was a daring operator. 
He excised the entire lower jaw in 1851 and in 1864, removed Meckel's 
ganglion and the superior maxillary nerve in 1856, and ligated the fem- 
oral for elephantiasis in 1851 . Besides journal articles he Avas the author 
of vl treatise on .... congenital dislocations of the head of the femur 
(New York, 1850, 8vo) and Contributions to operative surgery and sur- 
gical pathology (New York, 1877-83, 4to). 

Robert Alexander Kinloch (1826-91), a native of Charleston, gradu- 
ated in medicine from the University of Pennsylvania in 1848, after 
which he studied in London, Paris, and Edinburgh. During the Civil 
War he was medical director on the staffs of Generals Lee, Pemberton, 
and Beauregard. In 1867 he became professor of materia medica and 
therapeutics in the Medical College of the State of South Carolina, and 
soon afterward professor of surgery, which position he held to the time 
of his death. He was the most prominent surgeon in his State, and 
was the first in this country successfully to excise the knee-joint for 
chronic disease and to treat fracture of the lower jaw by wiring the 
fragments. He was also the first surgeon to open the abdomen in cases 
of gunshot wounds in which there is no protrusion of the viscera. His 
contributions to surgical literature were entirely to medical periodicals. 



THE HISTORY AND LITERATURE OF SURGERY. 143 

Other surgeons well known in their own States were George Hay ward 
(1791-1868), professor of sm-gery in the Harvard Medical School, Avho 
published some valuable surgical reports in journals and in a volume in 
1865; Jacob Randolph (1796-1848), surgeon of the Pennsylvania 
Hospital, who introduced lithotrity in America ; Horace A. Ackley 
(1812-59), professor of surgery at Cleveland, Ohio, 1843-56 ; Ely Ged- 
dings (1799-1878), professor of surgery in Charleston, S. C, the outlines 
of whose lectures were published in 1858; John Neill (1819-80), pro- 
fessor of surgery in the Philadelphia College ; Ernst Krackowizer 
(1821-75), a native of Upper Austria, who came to New York in 1850, 
and was surgeon of the Brooklyn City Hospital ; Julius F. Miner 
(1823-86), professor of surgery in Buffalo; Joseph C. Hutchinson 
(1827-87), professor of surgery in Brooklyn; and Josiah C. Nott 
(1804-73), professor of surgery at Mobile, but better knoM'n as a 
writer on ethnology. 

The history of surgery in the United States has been told by Gross 
(Am. Jour. 3fed. Sc, N. S., Ixxi. 1876, 431), and its triumphs in the 
way of first operations have been set forth by Dr. Dennis {Medical 
Record of New York, 1892, xlii. 637-648), and to these papers the 
reader is referred for details which there is not space here to give. 

In addition to anaesthesia, ovariotomy, and the foundation of modern 
gynascology, American surgeons have contributed much to the art in the 
way of perfecting apparatus for the treatment of fractures by extension ; 
of reduction of dislocations by manipulation ; of the treatment of dis- 
eases of the hip and spine ; of the ligation of large blood-vessels ; of 
the removal of tumors ; of the surgery of the brain, spinal cord, mouth, 
jaws, kidney, liver, and urinary organs. It is true that the scattered, 
unreported " first cases " of some of the great operations by early 
American physicians must be considered as entitling the individual to 
praise for his boldness or ingenuity rather than as "contributions to 
surgery," because it is not until such procedures have been made known 
to the profession and become a part of surgical literature or teaching 
that they have become useful ; but from the beginning of the history 
of the art we find that the majority of the "first operations" of all 
kinds have been made, not by distinguished professors and famous 
authors, but by men who were neither teachers nor authors, and the 
names of many of whom are unknown to this clay. This is true of 
amputations, lithotomy, herniotomy, trephining, excision of the breast, 
ligation of a wounded artery, Csesarean section, hysterectomy, ovari- 
otomy, and of the invention of many of the primitive forms of some of 
the most important instruments of the present day. " Les petits pro- 
phets," as Verneuil styles them, are worthy of all honor, and one of 
the objects of a history of surgery is to keep their names at least from 
being forgotten. American surgeons have contributed at least a fair 
share to the common stock of knowledge in the past, and it seems prob- 
able that they will do still more in the near future. They have been, 
for the most part, " practical men :" it is only within the last twenty 
years that the scientific problems of surgical pathology have been the 
subject of experiment and study in this country, but it is quite prob- 
able that the John Hunter or Joseph Lister of America is noAV busy 
with his preliminary work. 



144 THE HISTORY AND LITERATURE OF SURGERY. 

A most important step in the progress of medicine was made when 
physicians and surgeons began to form associations and societies for the 
purpose of mutual improvement and for the publication of papers read 
before them, rather than for guarding trade interests ; and the trans- 
actions of such societies form a most valuable section of medical litera- 
ture. The first of these societies which was devoted specially to sur- 
gery, and whose publications were important, was the Acadlmie royale 
de chirurgie, the memoirs of which appeared in 5 quarto volumes (Paris, 
1743-74, and again in 15 vols. 12mo, Paris, 1771-87, in 5 vols. 8vo, 
Paris, 1819, and in 3 vols. 8vo, Paris, 1838). 

The Il&noires and Bidletins of the Soci6t6 de Chirurgie de Paris, 
published from 1847 to the present time, and forming 52 volumes; the 
Verhandlungen of the Deutsche Gesellschaft fiir Chirurgie, in 35 vol- 
umes, 1872-93 ; the Transactions of the American Surgical Association, 
in 10 volumes, 1883-92 ; and the Proces-verbaux, m&moires, etc. of the 
CongrSs frangais de Chirurgie, — are the most important of the purely 
surgical publications of this class in the present century. No surgical 
association publishing professional reports has existed in Great Britain, 
the Royal Colleges of Surgeons of Edinburgh, of England, and in Ire- 
land not having undertaken this line of work. 

The following is a list of the most important journals devoted 
especially to general surgery, arranged in order of date : 

Chirurgische. Biblioihek, von August Gottlieb Kiohter, 1771-96, 8vo, Gbttingen 

u. Gotha. 
Journal de Chirurgie, par Pierre-Joseph Desault, 1791-92, 8vo, Paris. 
Bibliotliek fur die Chirurgie, Hrsg. von C. J. M. Langenbeok, 1805-13, 8vo, 

Gbttingen. 
Neue Bihliothek fiir die Chirurgie und Ophthalmologie, Hrsg. von C. J. M. 

Langenbeok, 1815-28, 8vo, Hannover. 
Journal der Chirurgie und Augea-HeHknnde, Hrsg. von C. F. Graefe und Ph. 

von Walther (quarterly), 1820-50, 8vo, Berlin. 
Giornale di C hirurgia-pratica, compilato dal dott. G. Canella, 1825-29, 8vo, 

Trento. 
Annales de la chirurgie frangaise et itrangire, publiees par MM. B(5gin, Mar- 

chal, Velpeau et Vidal, 1841-45, 8vo, Paris. 
Journal de Chirurgie, par M. Malgaigne, 1843-46, 8vo, Paris. 
Archiv fiir klinische Chirurgie, Hrsg. von Dr. B. von Langenbeok, red. von 

Billroth und Gurlt, 1860-94, 8vo, Berlin. 
Deutsche Zeitschrift fiir Chirurgie, Hrsg. von Bardeleben (et al.) ; red. von 

C. Hueter und A. Liicke, 1872-94, 8vo, Leipzig. 
Centralhlatt fiir Chirurgie, Hrsg. von L. von Lesser, M. Schede, H. Till- 

manns (weekly), 1874-94, 8vo, Leipzig. 
Revue de chirurgie, r^dacteurs en chef, MM. Nicaise et F. Terrier ■ direc- 

teurs, MM. Oilier et Verneuil, 1881-89, 8vo, Paris. 
Annals of Surgery, a monthly review of surgical science and practice, edited 

by L. S. Pilcher and C. B. Keetley, 1885-94, 8vo, St. Louis. 
Archives of Surgery, by J. Hutchinson (quarterly), 1889-94, 8vo, London. 



SURGICAL PATHOLOGY, mCLUDING INFLAM- 
MATION AND THE REPAIR OF WOUNDS. 

By W. T. councilman, M. D. 



I. INFLAMMATION. 

Inflammation is one of the most important subjects in medicine 
and surgery, and one of the most difficult to comprehend. It has 
played an important part in the history of medicine, and most of the 
theories of disease formerly held were more or less based on conceptions 
of its nature. It is only in comparatively recent years, when patient 
observation and experiment have taken the place of theory, that the true 
nature of inflammation has been better understood. 

Were we to take up all the phenomena of inflammation and study 
each process fully, it would practically include all pathology. So exten- 
sive is the subject, and so intimately is it related to other pathological 
processes, that it has recently been proposed to abolish the term " inflam- 
mation " entirely, and to consider the various phenomena under other 
divisions of pathology where they naturally belong. The phenomena 
of inflammation are closely connected with the pathology of the circula- 
tion, with the degeneration and regeneration of tissue, with the action 
of bacteria, with injuries, etc. Still, it is well to have some one term to 
include the tissue-changes following an injury, and we may define inflam- 
mation as the sum of the phenomena which take place in the tissue as the 
effect of an injury. The object of these various phenomena is to over- 
come or to diminish the effects of the injury. The study of inflammatory 
processes may be well begun with the changes which take place in the 
blood-vessels, and in the connective tissue, which everywhere stands in 
close connection with these. 

It will be well to consider the character of the normal connective 
tissue and the relations which it has with the circulation. The con- 
nective tissue in the body serves the important function of binding 
together the various parts, and acts as a support to the blood-vessels, 
which, with this tissue, grow into the various structures in the course 
of development. The connective tissue varies in its structure. It is 
composed of cells and of fibres which diflFcr in their physical and chem- 
ical qualities. In places the fibres are loosely connected together, as in 
the areolar tissues, and in places they are compacted in close bundles, as 
in the tendon. The number of blood-vessels in this tissue varies greatly 
in the difi^erent parts of the body, the number standing in exact relation 
to the importance of the adjacent epithelial structures. Most of the 
blood-vessels in the connective tissue do not serve the purpose of its 

Vol. I.— 10 145 



146 



SURGICAL PATHOLOGY. 



nutrition, the tissue simply serving as a bed for their support. Where 
the blood-vessels in the connective tissue are for the nutrition of this 
alone, they are not found in such large numbers. The nutrition of the 
tissue is carried on by means of the lymph which passes through the 
walls of the vessels and circulates through the tissue. In some places 
there are no definite tracks taken by the lymph. In the subcutaneous 
areolar tissue there is a loose meshwork of fibres containing a variable 
number of cells, and the tissue is simply saturated with the fluids. In 
other places, as. in the cornea, the fibres of the tissue are compacted into 
a dense mass containing channels and spaces in which the cells lie' and 
in which the lymph circulates. In still other places the nutrition seems 
to take place through the cells alone. In the cartilage, for instance, there 
is a compact intercellular substance, with no spaces either around or be- 
tween the cells, so that the nutrition of this tissue is probably kept up 
from cell to cell. 

The vascular phenomena which take place in inflammation can be 
directly studied under the microscope in a transparent part, as in the 
web of the frog's foot or in the mesentery (Fig. 1). The mesentery of 

Fig. 1. 




Portion of the mesentery of a frog, showing normal circulation : a, a, small arteries iust breaking 
up into capillaries ; 6, b, small veins ; c, c, wandering cells (leucocytes in connective tissue). 

the frog is a thin tissue which is covered on the outside by a single layer 
of flat endothelial cells, beneath which is a layer of rather firmly-inter- 
woven connective-tissue fibres, with numerous blood-vessels, nerves and 
lymphatics. The arteries and veins in the mesentery are relatively more 
numerous than the capillaries, because the tissue mainly serves to support 
the vessels passing from its root to the intestine. Under the microscope the 



INFLAMMATION. 



147 



normal circulation can be studied and the gradual development of inflam- 
matory changes observed. In the various sorts of vessels diiferences in 
the character of the circulation may be recognized. In the arteries there 
is an evident pulsating stream. At each contraction of the heart the 
blood is swept along so rapidly that it is not possible to recognize the 
individual corpuscles. In the diastole the stream becomes slower and 
we can see the individual corpuscles. In the veins the movement of the 
blood is a continuous one, and is slower than in the arteries. In the 
capillaries the movement of the blood is slow and regular. Neither in 
the veins nor in the arteries do the red blood-corpuscles completely fill 
the vessel. We recognize a central core composed entirely of masses of 
red blood-corpuscles, and between this and the wall of the vessel is a 
colorless zone which contains no red blood-corpuscles, and in which here 
and there single white corpuscles roll along. In the frog's web it is 
necessary to injure the tissue either by chemical or mechanical violence 
to produce inflammation, while the mere exposure of the mesentery to 
the air produces sufficient injury to bring about all of the phenomena. 

Fig. 2. 




The same vascular territory as shown in Fig, 1, two hours after exposure. All of the vessels are 
dilated. The leucocytes are more numerous ; they have collected along the walls of the vessels, 
and in several places are passing through : at d diapedesis of the red corpuscles is shown, 
and at c emigration of leucocytes. There are large numbers of leucocytes m the connective 
tissue. 

If care be taken in placing the mesentery beneath the microscope to 
produce as little injury as possible, all of the phenomena will take place 
so gradually that the single steps can be easily followed. At first no 
changes at all are seen in the circulation. Under some circumstances the 
first change seen is a contraction of the small arteries. This is always tem- 



148 SURGICAL PATHOLOGY. 

porary, and is often not observed, and in any case it quickly gives place 
to dilatation. The dilatation of the arteries is accompanied by a great 
rapidity of circulation. The blood flows through all of the vessels with 
increased speed. Even in the capillaries the flow is sometimes so rapid 
that the individual corpuscles cannot be seen. Vessels appear which 
were previously invisible from their small size. The veins take part in 
the dilatation, and the flow in them is also more rapid. This is the 
stage of active arterial hypersemia. There is more blood brought to the 
part by the dilated arteries ; more passes through and is carried off by 
the veins. 

This condition of the circulation soon gives place to another (Fig. 2). 
The dilatation of the blood-vessels continues, but the current becomes 
slower. The circulation in the dilated capillaries may become so slow 
that they become filled with red blood-corpuscles, and appear as red 
lines running through the tissue. The slowing of the current and dila- 
tation of the vessels are much more evident in the veins than in the 
capillaries, and a marked change takes place in the plasma-zone of the 
veins. In the normal circulation the white corpuscles are confined to 
this zone, and they roll along the wall in the clear fluid. These cor- 
puscles gradually increase in number, and the entire plasma-zone of the 
vein becomes filled with them. Although the blood-current of the vein 
is slow, the progress of the white corpuscles in the plasma-zone does not 
keep pace with that of the red corpuscles in the centre. They will fre- 
quently cling for a time to the wall of the vessel, and then again be 
swept away by the current. Numbers of them remain, and finally the 
wall of the vessel becomes lined with them. These corpuscles in the 
plasma-zone undergo rapid amoeboid changes, and may move from place 
to place along the vessel. Some of them become apparently fixed to the 
wall of the vessel, and then a striking phenomenon takes place. A small 
bud appears on the outside of the vessel opposite the point at which a 
white corpuscle adheres. This projecting bud gradually becomes larger, 
and at the same time that part of the corpuscle inside the vessel becomes 
smaller, and after a variable length of time the corpuscle passes 
entirely through the wall of the vessel. This passage of the white cor- 
puscles through the walls of the vessels is spoken of as emigration, and 
when it once begins it goes on with considerable rapidity, until finally 
the tissue outside of the blood-vessels becomes filled with these cor- 
puscles. They accumulate in the tissue and lie in the meshes between 
the fibrils and in the lymph-spaces (Figs. 3 and 4). The emigration is 
not always easily observed. To see it under the best circumstances 
vigorous frogs should be selected and care taken in spreading the mem- 
brane out to produce as little injury as possible. It is much more easily 
seen in the vessels of the bladder than in those of the mesentery. The 
bladder can be filled with salt solution, turned out through the rectum, 
and directly observed. Sometimes it takes more than an hour for the 
corpuscle to pass through the wall of the vessel. The white corpuscles 
accumulate in the dilated capillaries, but to a much greater extent in the 
veins. Both the red and the white corpuscles pass through the walls of the 
capillaries. The red corpuscles may also pass through the walls of the 
veins, but this is comparatively rare. This passage of the red corpuscles 
through the walls of the vessels is called diapedesis. They pass through 



INFLAMMA TION. 



149 





Diagrammatic view of inflammatory changes in a small vein : a, normal circulation, showing 
plasma-zone ; &, c, d, successive changes, showing dilatation, accumulation of leucocytes, and 
emigration. 

the walls of the capillaries in much greater numbers than the white 
corpuscles. 

Not only do the white and red corpuscles pass through the walls of 



Fig. 4. 




The process of emigration, observed under high power. The blood is supposed to flow on the left 
of the line in the direction indicated by the arrow. The tissue is on the right, x 1000. (After 
Thoma.) 



150 SURGICAL PATHOLOGY. 

the vessel, but the fluid portions of the blood also pass through. This, 
of course, cannot be directly observed under the microscope, but we can 
easily see that the tissue becomes thicker and infiltrated with fluid. A 
part of the fluid is retained in the meshes of the tissue, and a part passes 
directly through to the surface. These vascular changes last for a con- 
siderable time, and, if the mesentery of the frog has remained under 
observation a long while or if it be allowed to become dry, the circula- 
tion will finally cease and the part will become gangrenous. If care be 
exercised in the preparation of the specimen and the mesentery be 
replaced in the abdominal cavity, the vessels in the course of a few days 
will return to their normal condition. 

These are the main vascular phenomena which can be observed 
directly under the microscope. The process in all animals is the 
same. Thoma has observed the circulation in the mesentery in the 
small mammalia, under both normal and pathological conditions, and 
the same phenomena occur. The same process may be observed in the 
wing of a bat under the microscope, but in this case it will be necessary 
to produce some mechanical or chemical injury to the tissues, the mere 
exposure under the microscope not being sufficient. 

The inflammatory changes in the circulation may with advantage be 
studied in the frog's tongue. This contains more vessels than the mesen- 
tery and is relatively richer in capillaries. The tongue is attached to 
the jaw by its anterior extremity, and it can readily be drawn from the 
mouth, spread out over a cork ring, and the circulation observed. 
Inflammation may be produced by the application of dilute croton oil 
(1 drop of croton oil to 40 of olive oil) to the surface, removing it in a 
few minutes, otherwise it will produce coagulation of the blood in the 
vessels with entire cessation of the circulation. The same phenomenon 
which is seen in the mesentery takes place here. There is a period of 
intense active hypersemia which gives place to stagnation, Avith emigra- 
tion of white and red corpuscles and increased transudation. The 
tongue becomes swollen from infiltration with fluid and cells. The 
changes are the more striking the more limited is the injury to the 
tissue. The croton oil tends to diffuse all over the surface, but a cir- 
cumscribed inflammation may be produced by touching the surface with 
a crystal or a pointed stick of nitrate of silver. Various degrees of 
vascular disturbance may be seen, which is most intense immediately 
around the eschar which has been produced by the caustic, and which 
gradually gives place to the normal circulation. The caustic produces, 
where it comes in contact with the tissue, coagulation of the blood in 
the vessels, with cessation of the circulation and necrosis of the tissue. 
The necrotic tissue is converted into a brown slough which is presently 
cast off. Immediately around the eschar is a dark-red zone. In this the 
blood-vessels are greatly dilated, the circulation is very slow, in places 
completely stagnant, and the tissue between the vessels is filled with red 
corpuscles which have passed through the walls. The redness immediately 
around the necrotic spot is principally due to hemorrhage by diapedesis. 
Even with the naked eye it can be distinguished from the redness due 
to hypersemia by its greater intensity and diffuseness. Outside of this 
comes a zone in which the vessels are dilated, the circulation is slow, and 
numbers of corpuscles, both white and red, but principally white, are 



INFLA3IMA TION. 



151 



passing through the walls of the vessels and accumulating in the tissue. 
This zone gradually fades off into one in which there is active arterial 
hypersemia. In this way all the changes which gradually develop in the 
mesentery can be seen taking place at one time. Here, as in the mesen- 
tery, it is evident that there is also an increased exudation of the fluid 
portions of the blood, because the tissues become swollen and oedematous. 
These areas, which we have referred to as zones, are not sharply marked, 
but one gradually gives place to the other. 

The same process can be studied on non-transparent parts by harden- 
ing them at various intervals after the production of the injury and 
examining the sections. Acute inflammation may be excited in the ear 
of a rabbit by rubbing it with croton oil. The oil should be diluted 
with 5 or 6 parts of olive oil, otherwise a total necrosis of the tissue 
may be produced. Almost immediately the ear becomes actively red. 
In twenty-four hours it is red and swollen. The redness is not always 
due to hypersemia. Here and there small, irregular red splotches may 
be seen which are due to hemorrhage into the tissue. The swelling 
involves the entire ear even if the croton oil was only applied to the tip. 
On the inside of the ear small vesicles filled with clear fluid are fre- 
quently found (Fig. 5). Sections of the ear after hardening in various 

Fig. 6. 






Section of ear of rabbit thirty-six hours after the application of croton oil ; the connective 
tissue is swollen from infiltration with serum, leucocytes, and fibrin : o, epidermis ; b, vesicle- 
formation ; c, accumulation of leucocytes around necrotic hair- follicles ; d, fibrin ; e, muscular 
layer ; /, perichondrium ; g, cartilage. 

solutions — of which Fleming's solution is the best. — show the vessels 
dilated, and in some cases entirely filled with white corpuscles. Fre- 
quently the white corpuscles are confined to the inner lining of the 
veins, and in favorable sections they may be caught in various stages of 
emigration. In the areas of hemorrhage the congestion is intense, the 
tissue is filled with red corpuscles, but no rupture of the vessels can be 
made out. In the tissue everywhere there are immense numbers of cells 
of the same appearance as those within the vessels. They are usually 
more numerous close beneath the epidermis, and the tissue may be so 



152 SURGICAL PATHOLOGY. 

packed with them that nothing more can be seen. They are not only in 
the tissue beneath the epidermis, but numbers of them have entered 
into this, lying in the spaces between the cells, and in the fluid in the 
small vesicles numbers of them are seen. Toward the middle of the 
ear, where the tissue is looser, the white corpuscles are less numerous, 
and the meshes of the tissue are forced apart by infiltration with the 
fluid which has escaped from the vessels along with the leucocytes. In 
the swollen tissue toward the root of the ear, away from the area of 
injury, there are few or no leucocytes. Fibrin in various amounts may 
he contained in the tissue. 

If an injury be produced in non- vascular parts, the same changes 
which are seen in the vessels of the mesentery or in the vessels of the 
rabbit's ear will take place in the surrounding vessels which provide the 
nutrition for the non-vascular territory. The cornea has usually been 
selected for the study of inflammation in non-vascular tissues. If the 
central portion of the cornea of a rabbit be injured by touching it with 
a stick of nitrate of silver or caustic potash, a necrosis of the tissues 
limited to an area not exceeding 1 to 2 mm. in diameter may be pro- 
duced. The tissue immediately affected by the caustic becomes white 
and opaque ; it afterward becomes dry, and a scab is produced which is 
thrown off. For a time no change will be perceived in any portion of 
the cornea, either immediately around the injured tissue or at a dis- 
tance. If a very thin cornea, as the frog's, be chosen for the experi- 
ment, the corneal corpuscles immediately around the injury are more 
easily seen than elsewhere, and this is doubtless due either to coagula- 
tion of the protoplasm of the cell or to changes which have taken place 
in the intercellular substance. In the area of the eschar there has been 
total destruction of the cells and of the intercellular substance as well, 
but around this, where the action of the caustic was less intense, it is 
probable that necrosis of the cells with coagulation of the protoplasm 
has been produced without any alteration in the character of the inter- 
cellular substance. In the course of a few hours changes begin to 
appear in the periphery of the cornea close to the sclera. The first 
change which is appreciable is a slight cloudiness around the entire 
periphery of the cornea if the injury has been produced exactly in the 
centre. If the caustic was applied closer to one margin, the cloudiness 
will begin on the margin nearest the injury. The cloudiness rapidly 
increases, and extends over the entire cornea up to and around the 
injured portion. At first the entire tissue between the sclera and the site 
of the injury is clouded, but the cloudiness gradually becomes more 
marked around the injury, and the periphery of the cornea after three 
days may become completely clear. When the cornea is removed, split 
up into thin lamella, and examined, it is found that the cloudiness is 
due entirely to the presence of leucocytes in the lymph-spaces of the 
tissue. If the vessels of the sclera are examined in the beginning of 
the cloudiness, the same changes are found in them which were seen in 
the vessels of the frog's mesentery and tongue. 

The experimental study of inflammation of the cornea has played a 
most important part in the development of our knowledge of inflamma- 
tion. It formed the battle-ground between the adherents of Cohnheim, 
who believed that the cells in an acutely inflamed tissue were exclusively 



INFLAMMATION. 153 

derived from emigration of leucocytes from the vessels, and the adhe- 
rents of Virchow (and later Strieker), who believed that if emigration 
of leucocytes took place at all, it only played a subordinate role, and 
the new cells were derived from multiplication of the fixed cells of the 
tissue. 

The cornea being a non-vascular organ, it was first thought that the 
new cells which appeared in it after inflammation was excited must be 
derived from the fixed cells. Cohnheim showed that the new cells 
do not first appear around the injury, but in the periphery, and thence 
gradually make their way to the centre ; further, that examination of the 
vessels of the sclera showed the same changes which had been observed 
in the frog's mesentery. He showed further, in a most ingenious 
way, that the cells came from the vessels. It was known that when car- 
mine, cinnabai', or any finely-divided solid substance was injected into 
the circulation, the white corpuscles of the blood would take up the for- 
eign material. He injected such substances into the abdominal vein of 
a frog, and found them in the new cells of the inflamed cornea. Ac- 
cording to the theory of inflammation developed by Cohnheim, which 
was accepted without reserve by his pupils, the essential feature of 
inflammation is an alteration of the walls of the blood-vessels, in con- 
sequence of which they become more permeable, and allow not only the 
fluid parts of* the blood to pass through more easily, but the corpus- 
cles as well. The tissue-cells played no part in the process, and not 
only the pus-corpuscles, but all of the new cells found in the inflam- 
matory area, came from the blood. 

Cohnheim was not the first to observe the emigration of the leuco- 
cytes. His observations were made in ignorance of the earlier work on 
the subject, but he saw the importance of the process and investigated 
farther. Colinheim's first observations on the cornea were published in 
1867. As early as 1842, Gulliver described the cells found in severe 
inflammation and suppuration, and compared them to the white corpus- 
cles. He seems also to have been the first to observe an increase in the 
number of white corpuscles in the blood during the process of inflam- 
mation. Addison in 1845 called attention to the similarity of the blood-, 
lymph-, and pus-corpuscles. He found that all these cells had amoeboid 
movements, that they resembled one another greatly, and thought it 
possible that they might be the same cells. Quitzman, who reviewed the 
article of Addison in Canstatfs Jahresberieht, says that it shows great 
penetration and admirable observation, but that the only proof of the 
identity of the pus-cells and the leucocytes would be the observation of 
the actual passage of the leucocytes through the walls of the vessels. 
Various other observers after this called attention to the similarity in 
the appearance of white corpuscles and pus-cells, and in some of the 
atlases of pathological anatomy pus-cells and white blood-corpuscles are 
shown side by side. Virchow in numerous publications mentions this 
similarity. The actual proof of the matter ■\\^as given by Waller in 
England in 1849, but his observations attracted little attention and were 
soon forgotten. Then the matter rested until Recklinghausen in 1862 
showed that the normal connective tissue contained cells, similar to the 
leucocytes, which wandered through the tissue in the lymph-spaces. 
Although we know now that the leucocytes form the great mass of the 



154 SURGICAL PATHOLOGY. 

cells in the exudation in an acute inflammation, they are not the only- 
ones present, and the essential feature of inflammation is not the lesion 
of the vessels. 

For the excitation of inflammation an injury of the tissue of some 
sort must be produced, and the mode by which the injury is produced is 
of little importance. The injury may be from a trauma, and a lesion 
of continuity may be produced. In many cases it is difficult to show 
the anatomical lesion which the injury has produced. Pressure or trac- 
tion exerted on a tissue may act as a trauma, and the extent of the 
injury will depend upon the elasticity of the part. The consequence of 
pressure may be the severance of the connection between certain parts, 
or, when the pressure is of longer duration, the nutrition of the part 
may be aifected and necrosis take place. Very slight mechanical injury 
in individuals with very vulnerable tissues may produce evident inflam- 
mation. In the case of the mesentery we have seen that even the lay- 
ing bare of a part which is ordinarily covered may develop inflamma- 
tion. Zahn has shown that when the mesentery is fully protected from 
drying and other injuries, and preserved from contact with the bacteria 
in the air, it may remain exposed for hours without inflammation tak- 
ing place. The chemical injuries are probably more extensive than the 
traumatic. They may directly produce a necrosis of the tissue, with 
coagulation of the cells and intercellular fluid, or they may exert an 
injurious action on certain special cells. The injurious action of bacteria 
is probably for the most part chemical, the tissue being aifected by the 
substances which they produce. The action of some of the bacteria 
on the tissues is not inflammatory : they may exert a specific action 
on the cells, causing them to proliferate and to produce definite new- 
formations of tissue. Even this action may be accompanied by in- 
flammation, for all such newly-formed tissues are prone to degeneration, 
and the tissue reacts to the injury of these abnormal products just as it 
does to injuiy of its normal constituents. Heat and cold may excite 
inflammation if they are of sufficient intensity or their action is suf- 
ficiently prolonged to have an injurious influence. In the same way, if 
injury be produced by interference with the normal blood-supply of any 
part, inflammation is excited around the injured tissue. Electrical stim- 
ulation cannot excite inflammation unless it be of such a nature that 
the tissue is directly injured. Foreign bodies only act as exciters of 
inflammations by the injury which they produce in the tissue around 
them. Even in the inflammations of internal organs which are far re- 
moved from the dangers of traumatism the same thing is true. The 
injury to the tissue which is the cause of inflammation may be due 
to the presence in the tissues of chemical substances which are formed 
elsewhere in the body, and which exert an injurious action on certain of 
its cells. The inflammation of the kidney produced by chrome salts and 
cantharidin are examples of this. 

Certain phenomena -sdiich are easily appreciable have since the time 
of Celsus been regarded as indicating inflammation. They are in some 
cases more evident than in others, and certain of them may be absent or 
predominate over the rest. They appear in their most typical form in 
acute inflammations of the skin. If we take for example the furuncle 
or the infectious inflammation A\hich develops in the skin around the 



INFLAMMATION. 155 

hair-follicle or glands, we find at the height of the process that the in- 
flamed area is redder than the surrounding skin. It is warmer to the 
touch, and if the temperature be taken with a surface thermometer, it 
may be several degrees warmer than the neighboring skin. It is swollen, 
appears as an elevation, and is painful. 

The redness is due to the greater amount of blood which is contained 
either in the vessels or, in the form of hemorrhage, in the tissues of the 
part. The character of the redness varies. In the early stages of the 
inflammation and at the periphery it is a bi'ight red, almost approaching 
the color of arterial blood. As the inflammation advances, and in the 
centre of the furuncle, it changes to the dark color of venous blood. 
"When the blood is contained in the vessels alone, the redness may be 
made to disappear by pressure, the blood in the dilated vessels being 
driven out of them. The redness is also due to hemorrhage in the tis- 
sue. The areas of hemorrhage generally appear as circumscribed spots, 
distinguished from the hypersemia by the more intense color. They are 
easily seen in the inflamed ear of the rabbit, and are most marked where 
the action of the injurious agent has been most intense. By varying the 
dilution of the croton oil which' is applied to the ear the amount of the 
hemorrhage in the tissue varies, and is always greatest when the less 
diluted oil is used. There is no tissue in the body so well adapted 
to show inflammatory hypersemia and hemorrhage as the acutely in- 
flamed pleura. When this is stripped off and held to the light, it is 
of a bright-red color, a beautiful network of dilated vessels can be seen, 
and between these the tissue has a general diffuse redness due to injec- 
tion of the capillaries. Here and there in the tissue can be seen red 
splotches varying in size from 1 to 10 mm. in diameter, which are due 
to hemorrhage. More blood is brought to the inflamed part by the 
dilated arteries, and more flows from it. This increased passage of 
blood through the inflamed area takes place in spite of the slowness of 
the circulation in the dilated veins. In the early stages of inflamma- 
tion, in which there is dilatation with increased rapidity of the circula- 
tion, it is evident that this must be the case, and in the later stages, in 
which there may be almost complete stagnation in the central portion of 
the area, in the periphery there is an active circulation in dilated vessels. 
Lawrence long ago showed that there was a greater flow of blood from 
an inflamed part by opening corresponding veins coming from an inflamed 
and from a normal part. 

There have been various theories advanced to account for the inflam- 
matory hypersemia. After Bernard showed the effect of cutting the 
sympathetic on the circulation of the rabbit's ear, the idea arose that 
the inflammatory hypersemia might be due to paralysis of the vaso- 
motor nerves. It can be shown that this is not the case. After sec- 
tion of the sympathetic the hypersemia develops at once ; in inflamma- 
tion it comes on slowly and extends slowly. Further, the hypei'semia 
produced by section of the sympathetic never reaches the intensity of 
the inflammatory hypersemia. If the ear is inflamed after section of the 
sympathetic, an intense hypersemia develops — more intense, as a rule, 
than the inflammatory hypersemia of the ear with a normal nerv(jus 
supply. Then the opposite idea was held, that the effect of the injury 
was to produce a spasmodic contraction of the arteries, so that there 



156 SVBGIOAL PATHOLOGY. 

was really a diminished supply of arterial blood to the part ; the hyper- 
semia then was supposed to be due to the entry of blood into the inflamed 
part from surrounding parts by the collateral circulation. There is 
usually in inflammation a temporary contraction of the arteries, but 
this may be entirely absent, and it quickly gives place to dilatation. The 
theory of stasis has also been used to account for the hypersemia. This 
theory was intimately connected with the humoral pathology and was 
advocated by Boerhaave. It was supposed that in inflammation the 
character of the blood was altered, the corpuscles becoming more adhe- 
sive, and in consequence flowed through the vessels with more difficulty 
and accumulated in the inflamed part. These views with regard to the 
hypersemia of inflammation have been given up, and the two theories at 
present used to explain it are that of Cohnheim and that of Virchow. 
Cohnheim explains all the vascular phenomena of inflammation by an 
alteration of the walls of the blood-vessels produced by the action on 
them of the agent causing the inflammation. Virchow explains the 
congestion by an alteration in the attraction between the blood and 
the tissues. Cohnheim supposed that the changes in the vessels were 
passive in character, and were due to the effect of the injury on them, 
and he attempted to prove this in various ways. He showed that when 
the blood was cut off from the vessels for varying periods, and then 
again turned into them, all the phenomena of inflammation could be 
produced, the degree depending on the length of the anaemic period. 
By cutting off the blood from them he supposed the nutrition of their 
walls was affected, and thus an injury limited to the blood-vessels was 
produced. He does not attempt to define the character of the altera- 
tions which the vessels undergo, and supposed that there might be either 
chemical or physical changes produced in them which were so delicate 
that they could not be detected by our methods of investigation, and 
which manifested themselves only by their effects. Almost all that we 
know about pathological alterations in blood-vessels relates to the various 
degenerations of their walls. It is certain that there can be no altera- 
tion of the walls of the blood-vessels without affecting the tissues at 
the same time. The effects of the ansemia produced by shutting off 
the circulation from the ear will be felt by the tissues as well as by 
the walls of the vessels, and the inflammation which follows will be due 
to the injury produced in the tissue. There is much which is opposed 
to the theory of Cohnheim. The dilatation of the vessels extends far 
beyond the area immediately acted on by the trauma. Samuel has 
shown that if the upper portion of a rabbit's ear be inflamed bv ex- 
posing it for a few minutes to water of the tempei-ature of 64° C., an 
intense congestion is produced which affects not only the vessels in 
the part which has been directly acted on by the heat, but extends to 
the main artery of the ear. The central artery is dilated in its entire 
course and pulsates strongly. When the artery is cut a considerable dis- 
tance below the inflamed area, more blood flows from it than from the 
artery of the normal ear at the same point. In the case of the cornea 
it is difficult to assume that the action of the injury producino- the 
inflammation could have extended to the vessels of the sclera. It may 
probably be assumed for a chemical injury, but in the case where an 
inflammation is excited by passing a thread through the centre of the 



INFLAMMATION. 157 

cornea it is impossible to suppose that the mechanical trauma could have 
affected vessels so remote. If one hand be acutely inflamed, the arteries 
on the inflamed side are dilated and pulsate more strongly than on the 
normal side. In vascular tissues the inflammatory phenomena, the dilata- 
tion, the emigration, etc., do not take place so far away from the injured 
tissue as the sclera is from the centre of the cornea. Only those vessels 
Avhich are immediately concerned in the nutrition of the tissue will be 
affected. All the more recent work on the circulation has removed the 
blood-vessels more and more from a passive role in nutrition. The 
increased transudation is not due to the vessels becoming simply more 
permeable, but is due to active changes in the vessels brought about by 
influences acting upon them. The view of Virchow that the hyper- 
semia is the result of an alteration in the attraction between the blood 
and the tissues is probably more nearly correct than that of Cohnheim. 

The blood-supply of an organ is regulated entirely by the need of the 
organ. An increase of function is accompanied by hypersemia. The 
hypersemia is not the cause of the increased function, but it is demanded 
by the greater needs of a tissue for blood when its functional activity is 
increased. In the case of a gland more blood must be brought to the 
part, not only to nourish the cells in their increased activity, but to sup- 
ply a greater amount of material from which the specific substances 
secreted can be drawn. We know from the work of Heidenhain that 
in the ordinary process of secretion the capillaries do not play a passive 
part, allowing indefinitely all the fluids of the blood to pass through, 
from which the cells may take up certain specific elements, but the cap- 
illaries themselves may be regai'ded as true secreting structures, and they 
allow only the substances necessary for each particular tissue to pass 
through them. When a portion of an organ undergoes atrophy or when 
there is a permanent loss of substance, however brought about, not only 
will the supply of blood be diminished by a reduction of the calibre of 
the blood-vessels brought about by contraction of the muscles, but it will 
be permanently lessened by the formation of a tissue inside of the 
artery which brings about a permanent diminution of its calibre. On 
the other hand, when a tissue calls for a greater amount of blood than 
can be supplied by the artery, as in the case of collateral circulation 
when one of a series of small arteries takes the place of a larger, the 
calibre of the artery will not only be increased by a relaxation of its 
walls, but it will be permanently increased ; it will, in fact, become larger 
by growth. 

The hypersemia in inflammation is apparently called forth by the 
needs of the tissue for repairing, and for in other ways setting aside 
the consequences of the injury. 

The temperature of the inflamed part is increased. It is due solely 
to the fact that more heat is brought to the part by the increased afflux 
of arterial blood, and the rapidity of the circulation does not allow suf- 
ficient time for its dissipation. When active hypersemia is produced in 
the rabbit's ear by section of the sympathetic, it can easily be shown 
by folding the ear over an ordinary thermometer that the temperature 
of the inflamed ear is four or five degrees above that of the normal. 
The first exact experiments with regard to the temperature in inflamed 
parts were made by John Hunter. Hunter showed that the fluid con- 



158 SURGICAL PATHOLOGY. 

tained in a hydrocele had a temperature when it was tapped of 33.3° 
C, and on the next day, after actual inflammation had taken place, 
the introduction of a thermometer into the sac showed a temperature 
of 37.8°. He showed further that when an acute inflammation was 
produced in internal parts, as in the pleura, the peritoneum, the peri- 
cardium, or the deep muscles in the back and legs, the temperature of 
the inflamed part not only did not exceed, but it frequently did not 
reach, the normal temperature at the same place. As a result of his 
experiments Hunter taught that in local inflammation the tempera- 
ture does not exceed that of the interior of the body. The correctness 
of Hunter's conclusion was opposed later by Simon and Weber, who 
found in peripheral inflammations produced by fracture of bones or by 
the injection of croton oil into an extremity that the temperature of 
the inflamed part was greater than that of the blood in the artery 
going to the part. This was in accord with the theory of Zimmerman 
which afterward appeared. It is known that a general systemic affection 
in which the temperature of the entire body is increased frequently 
accompanies a local inflammation. This is the inflammatory or traumatic 
fever. Zimmerman advanced the theory that the inflamed part repre- 
sented a local production of heat which led to increased temperature in 
the entire body, the increased temperature of the body being due to the 
heating of the blood in the inflamed part. A repetition of all of these 
experiments with more exact methods of measuring the temperature 
by the use of the thermopyle and the galvanometer, which were carried 
out by Jacobson and his scholars, showed that the temperature of the 
rabbit's ear in the course of inflammation produced by croton oil is 
higher than that of the normal ear, but considerably lower than that 
of the rectum or vagina of the animal ; and further, that in inflamma- 
tion of the deep muscles of the leg there is very slight or even no 
increase of temperature over that of the sound leg. In acute pleurisy 
and peritonitis the temperature of the inflamed cavity is the same as, 
or sometimes less than, that of the blood inside of the heart. The 
degree of heat in the inflamed part will differ materially according to the 
character of the inflammation. In the early stages of inflammation, Avhen 
there is an active arterial hyperaemia, the temperature will be greater 
than in the later stages, when the active hypersemia has given place to 
stagnation. Also, in an intense inflammation produced in the rabbit's 
ear, in which there is stagnation and a great deal of hemorrhage in the 
tissue, the temperature, instead of being greater, may be considerably less 
than that of the opposite ear. In any experiments with regard to tem- 
perature in inflammation the temperature of the inflamed part must 
always be compared with the temperature of the interior of the body of 
the same animal. A considerable amount of fever may be produced by 
even a comparatively slight degree of inflammation, and if the tempera- 
ture of the inflamed part were simply compared with that of the usual 
normal temperature of the animal, erroneous conclusions might be drawn. 
Pain in inflammation is due to the distention of the part and the 
pressure which is produced on the nerves, or by the direct action of the 
inflammatory cause on the nerves. The character of the pain will differ 
in different tissues of the body and in the various sorts of inflammation. 
In very acute inflammations, when the swelling has taken place rapidly, 



INFLAMMATION. 159 

the pain frequently has a marked pulsating character, because every 
addition of blood which is brought to the part by the systole of the heart 
will temporarily increase the pressure on the nerves, and consequently 
the pain. It is evident that the pain in tissues poorly supplied with 
nerves will be less severe than in parts Avhich are extremely sensitive. 
The anatomical character of a tissue will also have an influence on the 
degree and character of the pain, which may be entirely disproportionate 
to the abundance of nerves. In inflammation of dense fibrous tissues, 
which are incapable of much distention, greater pressure and injury of 
nerves are brought about than in a part where the tissues are more lax. 
Inflammations of the periosteum or of the fibrous tissues about joints are 
intensely painful. Not only do these local conditions influence the 
degree and the character of the pain, but general conditions of the body 
may also exert an influence. A condition of hypersesthesia may be 
brought about either by local changes in the nerves of the inflamed part 
or by the effect of fever on the nervous centres. 

The swelling of the inflamed part is due to an increase of material in 
the part. There is not only an increased amount of fluid in the inflamed 
part, but the cellular elements are also increased. The volume of a part 
in tlie state of inflammation is also slightly increased by the mcreased 
amount of blood in the vessels, but this has so slight an influence that 
it may be left out of consideration. We know that hypersemia will 
produce an increase of volume. The fluid which is present in the in- 
flammatory tumor comes from the blood-vessels; the transudation is 
increased. Not only does the fluid accumulate in the tissues in this way, 
but there is an increased flow in the lymphatics going from the part. 
Cohnheim showed that when a canula is placed in a main lymphatic of 
the leg after an acute inflammation has been produced in the foot by the 
action of croton oil or hot water, there is a greatly increased flow of lymph 
as compared with the other side. On dissecting out the lymphatics 
coming from an inflamed part they are found full and turgid. Chemical 
analysis of the lymph in inflammation has shown that it is much more 
concentrated than the normal lymph. A solid residue of 6 or 7 per cent, 
has frequently been found in the inflammatory exudation in man, and 
Lasser has shown that the lymph from the inflamed foot contains 6|- to 
8 per cent, of solid constituents. The salts are not increased. All inves- 
tigators are agreed that they are found in almost the same proportions in 
the inflammatory transudations as in the normal lymph. The increased 
concentration depends entirely upon an increase in the amount of 
albumin. There is a marked difference between the character of the 
(edematous fluid in inflammation as compared with that of the ordinary 
dropsy from chronic passive congestion. The dropsical accumulations 
contain but little albumin, and the normal lymph has an intermediate 
relation between the two in the proportion of albumin. In inflam- 
matory lymph there is a greater tendency to coagulation than in 
normal lymph. Dropsical accumulations either do not coagulate at 
all or very slowly, and a soft clot is produced. Lasser found difficulty 
in obtaining lymph from the lymphatics of an inflamed part on account 
of its great tendency to coagulation, the canula becoming in a short time 
filled with the clot. The increased coagulability of the lymph is due in 
great part to the increased number of colorless corpuscles. 



160 SURGICAL PATHOLOGY. 

Cohnheim regards this alteration in the character of the transudation 
as due entirely to alterations in the walls of the blood-vessels. The 
character of the filtrate is altered, because the character of the filter, the 
wall of the blood-vessel, is altered. He rightly supposed that the 
increased transudation in inflammation is not due to a simple increase of 
pressure within the vessels, because the character of the fluid is diflerent 
from that in chronic passive congestion, which is due to such increase. 
It is impossible to compare exactly the character of the transudation 
in the two cases by observation of the fluid in the lymphatic vessels. 
In chronic passive congestion the lymph as it escapes from the vessels 
comes in contact with a tissue which is unaltered. In inflammation the 
lymph comes in contact with abnormal tissues. In the tissue of the part 
in which there is inflammation there are various changes taking place, 
various degenerations have been produced by the injury which has caused 
the inflammation, and all of these factors may exert an influence on the 
character of lymph flowing through it. It is probably true that in in- 
flammation the character of the transudation passing through the vessel- 
walls is diflerent froni the normal, and difiierent from that in chronic 
passive congestion. But its character is not due to changes which have 
taken place in the walls of the blood-vessels, in consequence of which 
they passively allow a diflerent fluid to pass through them, but the 
vessels actively secrete a difFerent fluid. The character of the transuda- 
tion may dififer also in the various sorts of inflammation. A different 
fluid is needed by the tissues, and there will be a difference in the tran- 
sudation, just as there is a different lymph secreted by the blood-vessels 
of the kidney as compared with that secreted by the blood-vessels of the 
pancreas. This increased flow of lymph in inflammation has a purpose- 
ful character independent of affording a greater degree of nutriment to 
the tissues. By it soluble chemical substances — substances either pro- 
ducing the inflammation of the tissue in the first place or substances 
which are produced in the inflamed area by the action of bacteria which 
may be there — are diluted or washed away. 

In the inflamed part the lymph will accumulate in the interstices 
of the tissue, in the lymphatic vessels and lymph-spaces, and give rise 
to- oedema of the part. By pressure it may be pushed from one place 
into another, just as by pressure the blood can be removed from the ves- 
sels of a part. A deep depression or pit remains at the seat of pressure, 
which will disappear when the fluid returns. There may be inflam- 
mations in which the swelling is due entirely or almost entirely to the 
increased fluid transudations. Such inflammations may be spoken of as 
oedematous inflammations, and they generally represent a milder degree 
of inflammation. One of the most marked examples of a simple (edema- 
tous inflammation is that produced by the action of the sun. We may 
have here a very mild degree of inflammation in which there is only 
hypersemia with increased fluid transudation. 

Samuel, in his work on inflammation, has very properly separated the 
oedema in an inflamed part due to the inflammatory cause from the 
oedema in adjacent parts which frequently supervenes on inflammation. 
Thus, when the extremity of a rabbit's ear is inflamed there will be 
oedema not only in the inflamed portion of the ear, but also lower down 
in the ear, where no injury of the tissue has been produced. This 



INFLAMMA TION. 161 

Samuel distinguishes as inflammatory oedema in contradistinction to the 
oedematous inflammation. It is due merely to an extension of the oedema 
from the inflamed territory, and is sometimes spoken of as collateral 
oedema. The same thing can be seen in the subcutaneous cedema of the 
chest-walls which sometimes accompanies inflammation of the pleura. 
This oedema was also studied fully by John Hunter, who speaks of it as 
being squeezed from the inflamed part into adjacent parts. 

The tumor contains, in addition to the fluid, a certain portion of solid 
material. In the first place, it contains a variable amount of fibrin. 
Not only is the lymph which passes from the inflamed part richer in 
fibrin than the normal lymph, but in many inflammations there is 
formation of fibrin, a certain amount of coagulation, in the inflamed 
part itself. In the inflammatory exudation all the necessary elements 
for the formation of fibrin are present. Fibrin is due to the action of 
a ferment, usually spoken of as the fibrin-ferment, on. certain substances 
in the blood. This fibrin-ferment, there is every reason to believe, is 
formed from the disintegration of cells. In the ordinary process of 
coagulation it is probable that the leucocytes of the blood form the 
source of the ferment, but it may be produced by the disintegration of 
the cells of the tissue. In the inflamed part there is an abundance of 
fibrinogen in the exudation, and the fibrin-ferment is produced by the 
disintegration of cells. Fibrin is present in almost any acute inflam- 
mation. On examination of the inflamed ear of the rabbit after suit- 
able hardening a varying amount of fibrin is found in the exudation, 
the amount depending largely on the intensity of the inflammation. In 
some cases there are only a few fibrillse scattered through the tissue, and 
in other cases there are large masses of it. In many cases the fibrin 
may be seen radiating out from the necrotic cells. The hardness of the 
inflamed part, especially the so-called brawny induration which is found 
in certain sorts of inflammation, is due to the presence of fibrin. In 
certain forms of inflammation the fibrin may be present in excessive 
amounts. 

In any inflamed part in which there is an increased number of cells 
in the tissues a certain number of red corpuscles will nearly always be 
found. With regard to these we know that they could only come from 
the blood-vessels, and they are found in varying numbers, dependent on 
the character and intensity of the inflammation. In some cases they are 
present in such excessive numbers that the inflammation is spoken of as 
hemorrhagic. These corpuscles escape into the tissues from the capillary 
vessels, and can easily be seen to pass through the walls of these vessels 
when the inflammation is directly observed under the microscope. 

A large proportion of the cells — and in some inflammations nearly 
all — are white corpuscles which have emigrated from the vessels. With 
the increased knowledge of the corpuscles of the blood which has come 
from its more careful study in recent years we know that the white cor- 
puscles difler materially from one another in form, and that they have 
different values and different origins. The most numerous corpuscles 
are the so-called polynuclear leucocytes. These form between 80 
and 85 per cent, of the entire number of leucocytes, and are cha- 
racterized by an irregular nucleus. This nucleus stains brightly, and, 
although spoken of as a multiple nucleus, it is in most cases a single 

Vol. I.— 11 



162 SUBGIOAL PATHOLOGY. 

nucleus divided into several masses which are connected together by fine 
filaments. These corpuscles also differ from one another in the chem- 
ical composition of their protoplasm. This is shown by their reaction 
to staining agents. In the great majority of them the protoplasm con- 
tains very fine granules which are stained with the neutral or basic 
aniline colors. In a certain proportion of them the granules in the pro- 
toplasm are larger and stain brightly with eosin. Next to these in 
number and importance are the so-called leucocytes of the blood. In 
these two sorts can be distinguished. The most numerous are corpuscles 
which are about the size of the cells contained in the lymph-glands, and 
which have a large round nucleus, and a very small amount of proto- 
plasm around this. There are a certain number of larger cells of the 
same character. Although other cells have been described in the blood, 
these are the only ones which need concern us in the study of inflamma- 
tion. In the corpuscles first described the nucleus frequently takes the 
shape of a horseshoe. 

The polynuclear leucocytes are the most numerous of the cells found 
in the swollen tissue in acute inflammation. In some cases they are ap- 
parently the only new cells found in the tissue. In the inflamed cornea 
in the early stages of inflammation the cells found in the lymph-spaces 
are exclusively these. There have been many theories advanced to 
explain how these cells pass through the walls of the vessels. The first 
idea held by Cohnheim was that the passage was effected by means of 
their amoeboid movements — that they crawled through the walls. The 
corpuscles when adhering to the walls before the emigration has begun 
show active amceboid movements, and when in the act of passing 
through, both the part outside of the vessels and that inside show active 
amoeboid motion. Cohnheim afterward gave up this idea, and con- 
sidered that the white corpuscles, like the red, did not pass through by 
means of their own activity, but by passive filtration. He was chiefly 
led to this view from the fact that when the blood-current ceased in the 
dilated veins the process of emigration ceased. There may be another 
explanation of this. The leucocytes are probably kept against the wall 
of the vessel by means of the blood-current, and probably by the con- 
tinuance of the circulation they are excited to more active amoeboid 
movements. Their collection in the vessels of the inflamed part is 
partly due to the slowness of the circulation, but more to a voluntary 
action on their part. The inflamed tissue exerts an attraction for them. 
Substances which have the power of stopping the amoeboid movements 
of the corpuscles also stop the emigration. Thoma has shown that 
when salt solution of the strength of 1 : 12 is injected into the blood 
the amoeboid movements of the leucocytes cease, and the process of emi- 
gration ceases in inflammation. If the frog is completely chloroformed, 
the action of the chloroform may extend to the leucocytes and stop any 
amoeboid movements, and emigration will not take place. Cohnheim 
supposed that the filtration of the corpuscles through the vessels was 
due to an alteration in the vessel's wall, together with the increased 
pressure. He did not attempt to define the character of this alteration, 
but supposed it might be physical or chemical. The most accurate 
observations on this subject seem to show that the leucocytes pass 
between the endothelial cells of the vessels. There are small openings 



INFLAMMATION. 163 

between these cells in the normal condition of the vessel, and these 
openings probably become larger when the vessel is dilated. Bouchard 
thinks that the endothelial cells in the vessels may contract and assume 
a round form, leaving large openings between them through which the 
corpuscles pass. The emigration of the leucocytes is due to active 
amoeboid movements on their part, possibly assisted by a more porous 
condition of the walls of the vessel. 

It is known that chemical substances have the power of attracting or 
repelling cells capable of independent motion. This was shown first by 
Engelman in certain of the myxomycetes. It is seen in a marked 
degree in bacteria. The phenomenon was carefully observed in the 
leucocytes by Gabrischweisky. He found that when capillary tubes 
were partly filled with certain substances and placed in the tissues of 
animals, the tubes became filled up with leucocytes. When they were 
filled with indiiferent substances, only a small number of leucocytes 
entered into them, and other substances exerted a repellant action. 
Necrotic tissue of all sorts attracts the leucocytes to it. No better 
proof can be given of this than the collection of leucocytes around a 
lesion in the centre of the cornea. Although they pass from the vessels 
of the sclera, they do not wander into the tissue at random, but march 
directly to the inflamed focus. What the nature of the chemical 
substance is which exerts this attraction for the leucocytes we do not 
know. It is produced in necrotic tissue everywhere. Although most 
of the bacteria have a decided action in attracting leucocytes, this attrac- 
tion is more strongly exerted when they are dead than when they are 
living. It is probable that substances are produced in the necrotic 
tissues which by diffusion extend their action to the vessels, producing 
in these the inflammatory phenomena. Not only is the influence felt 
on the vessels, but it extends to the cells within them, causing these to 
pass through the walls and to accumulate around the necrotic tissue. 

The cells in some inflammations, and in the early stages of all, are 
composed entirely of these polynuclear leucocytes. Along with them in 
other cases cells similar to the lymphocytes in the blood appear. 
Usually they appear somewhat later than the polynuclear leucocytes, 
and in inflammations of a less active character. They are jDrincipally 
formed in the outermost zone of the inflammatory area, and usually are 
seen in small groups around the vessels. There is much dispute about 
their origin. While all observers are agreed that the polynuclear leuco- 
cytes come from the blood, it is held by some that the small lymphocytes 
have the same origin. Others hold that they are formed by prolifera- 
tion of the tissue-cells. Baumgarten especially holds the former view. 
His studies of the cells in inflammation were made on the histogenesis 
of tubercle. The round lymphocytes enter largely into the structure of 
this, and he believed that they come from the blood and enter into the 
tubercle, which is at first formed of large cells derived from the tissue. 
Ribbert and Marchand also believe that these cells are leucocytes. In 
the more chronic inflammations the new cells may be almost exclusively 
of this character. There are many objections to these views. Although 
we are not able to study the course of inflammation so thoroughly in 
man and the mammalia as in the frog, still by the modern methods of 
histological technique we are able to study the process which is going on 



164 SURGICAL PATHOLOGY. 

in any one stage of inflammation. As far as I have been able to 
observe the process of acute inflammation in man by means of thin 
sections of tissue carefully hardened, the polynuclear leucocytes are the 
only ones which pass through the vessels. In acute inflammation of the 
skin the vessels of the papillae are closely packed with these cells, and 
they may be observed in every stage of passage. 

The origin of the cells in the inflamed territory has been a subject 
of dispute in pathology. Cohnhein at first believed that all the new 
cells were leucocytes, but he afterward modified his views, and admitted 
that in the later stages of inflammation regenerative phenomena took 
place in the surrounding tissue-cells, leading to the formation of new 
cells. The new cells so formed were distinguished from the inflamma- 
tory cells, and were destined to renew the tissue which had been de- 
stroyed. Cohnheim's view was directly opposed to that of Virchow. 
According to Virchow, the essential condition in inflammation is an 
altered nutrition of the tissue. In consequence of the injury — or, as he 
calls it, the irritant — the cells of the tissue were variously affected. 
They were roused t» an increased activity which might be simply nutri- 
tive or formative. They might increase in size, with an increase of their 
functional activity, or they might multiply. All of the vascular phe- 
nomena he considered to be secondary to this altered nutrition of the 
tissues, and due to this. Virchow was one of the earliest authors to 
recognize the similarity of the new cells in inflammation to leucocytes, 
but he supposed, in spite of the similarity, that they were formed by 
multiplication of the cells of the tissue. Virchow's views underwent 
some modification at the hands of Strieker. While Strieker does not 
deny the emigration of the leucocytes, he thinks that these form but a 
small part of the cells which are formed in the inflammatory exudation. 
He accepts the view of Virchow that most of the cells are derived from 
proliferation of the cells of the tissue, and he compares the cell under 
its ordinary conditions to a bent bow. He holds that they have a certain 
amount of stored-up formative energy, which under the influence of the 
inflammatory irritant can be expended in a new formation of cells, the 
inflammatory irritant acting as the unloosing of the arrow. Afterward 
he still further modified this view, holding that not only do the cells of 
the tissue proliferate, but new cells are formed from the intercellular 
tissue. This view, first given by Strieker, that a new formation of cells 
can take place from the intercellular substance, has been taken up by 
Grawitz. According to Grawitz, in the development of the tissue only 
a certain number of cells are used up in the formation of intercellular 
substance. Many of them, without losing their character as cells, be- 
come invisible and apparently form a part of the intercellular substance. 
Under the influence of the inflammatory stimulant these cells, which 
Grawitz speaks of as the slumbering cells, become visible, multiply, 
and form a large part of the cells in the inflammatory tumor. Cohn- 
heim was led to alter his former views as to the exclusive presence of 
leucocytes in the inflammatory tumor by the work done in his labor- 
atory by Senftleben. Various observers had described changes in the 
corneal corpuscles during inflammation. Virchow had described swell- 
ing and multiplication of cells in the periphery, and considered that the 
cloudiness of the tissue was due to such changes in the cells. Mxiltipli- 



INFLAMMATION. 165 

cation of the cells was described by His and numerous other authors, 
and Axel Key described changes in the cells immediately around the 
inilamed area. Most of these changes described in the cells were 
either falsely interpreted as cell-multiplication or they were degen- 
erative phenomena. Senftleben was the first accurately to describe the 
changes which take place in the corneal cells in inflammation, and to 
separate the newly-formed cells from the leucocytes. He showed that 
when the centre of the cornea was cauterized the corneal corpuscles 
immediately around the eschar were killed by the action of the caustic. 
The injury to the tissue extended farther than the formation of the 
eschar seemed to indicate. The necrotic corpuscles contracted, their 
processes were drawn in, and they became converted into formless 
masses. The corpuscles immediately outside of this area underwent other 
changes. They became larger and stained more brightly, the nuclei 
increased in number, and long processes were given off from them which 
extended up into the region of necrosis. Nuclei passed from the cells 
into these long processes, and in this way new cells were formed which 
took the place of necrotic cells, and represented not an inflammation, 
but a regeneration of the tissue. 

These changes in the cells only take place in the corpuscles adjacent 
to the necrosis, and no changes are seen in the cells in the periphery 
where the pus-cells are entering into the tissue. It has been shown 
that it is possible to produce such slight injuries to the tissue that there 
is little or no infiltration with leucocytes, and the changes may be limited 
to regeneration of the cells. In almost any sort of inflammation in any 
tissue the two processes of emigration of leucocytes and new formation 
of cells take place. The cellular proliferation takes place later than 
the emigration. It can be recognized by the various changes which 
take place in the nuclei preceding cell-division, and in general does not 
begin until two to four days after the receipt of the injury. The charac- 
ter and the arrangement of the cells can be easily seen in the small foci 
of inflammation which form around small masses of bacteria which have 
been carried as emboli into the tissue. These can be produced at will 
by the injection of pure cultures of the staphylococcus aureus into the 
ear-veins of rabbits, and their development observed by killing the 
animals at successive periods after the injection. Such foci will serve as 
general types of acute inflammation. The micrococci are found in a 
small vessel, either a capillary or a small vein, which they entirely occlude. 
They are probably not lodged here as an embolus filling up at once the 
entire vessel, but one or more lodge in the endothelium and the vessel 
becomes filled by their growth. In the older foci their growth extends 
beyond the vessel, and clumps of them may be found in the tissue. 
Around the group of bacteria there is a distinct necrosis of the tissue. 
In the necrotic mass the cells may sometimes be recognized, but more 
generally the whole is converted into a granular mass. In the periphery 
of the necrosis the tissue is infiltrated with polynuclear leucocytes. 
These form a wall around and extend into the necrotic tissue. It is 
probable that the necrotic tissue is formed, to some extent at least, 
by the leucocytes which have wandered into it so far that they have 
fallen victims to the same cause which produced the necrosis of the 
tissue. Although the wall of cells formed around the necrosis is, on 



166 SUBGICAL PATHOLOGY. 

the inside, composed entirely of leucocytes, on the outside these gradu- 
ally give place to mononuclear cells similar to the indifferent cells of 
granulation tissue and to the lymphoid cells of the blood. The more 
advanced the inflammation, the more numerous are they in the tissue. If 
the animal be killed twenty-four hours after injection of the bacteria, when 
the small inflammatory foci are not visible to the eye, the cells may be 
absent. Where they are formed in the tissues is a question. From their 
close relation to the blood-vessels, and from the fact that in the cells 
forming the vessels the earliest and most active cell-proliferation is seen, 
it seems probable that they are formed from these cells. In some of the 
inflammations produced by bacteria they may be so numerous as to con- 
stitute by far the majority of the new cells. Other cells make their 
appearance in the late stages of inflammation, but they are so obviously 
connected with repair and new formation of tissue that they will be con- 
sidered under that head. 

There is a purpose fulfilled by the presence of the leucocytes in the 
inflamed tissue. Whenever there is any dead material in the body, this 
becomes filled with leucocytes. In such material chemical substances 
are formed which exert an attracting force on the leucocytes. In 
the small foci of inflammation formed around masses of staphylococci 
they are attracted not only by the necrotic tissue produced by the 
bacteria, but by the bacteria themselves. Capillary tubes partly filled 
with staphylococci and placed in the tissues speedily become filled with 
leucocytes. They appear to pave the way for a new formation of tissue. 
It is by means of the leucocytes that the detritus of dead tissue is 
removed. In the acute inflammation produced by bacteria they form a 
wall around these, close up the lymphatics, and prevent to a large extent 
the further action of the organisms. Metschnikoff has shown that they 
have the power of taking up and destroying bacteria, and their presence 
is in this way a source of protection to the organism. This power of 
eating and destroying material is termed "phagocytosis." Another 
purpose which they serve is that of furnishing food to the large epithe- 
lioid cells which are concerned in the formation of tissue. There can 
be little doubt that an important purpose may also be served by the fluid 
exudation in washing out soluble injurious substances from the tissues 
and in diluting them. Most foreign bodies, especially those of an 
organic character, when introduced into the tissues, will produce to a 
limited extent inflammatory changes in the circulation in the vessels 
around them, with emigration of leucocytes which enter into the foreign 
body. Pieces of sponge or pith placed in the abdominal cavity become 
filled with leucocytes. Other substances have little or no effect in 
attracting them. Finely-powdered glass introduced into the tissue 
causes a new formation of tissue, an infiltration with round lymphoid 
or granulation cells, and finally a capsule formation ; and this may take 
place without the emigration of a single leucocyte. 

Little is known as to the manner in which the red corpuscles pass 
through the walls of the vessels, and the conditions favoring this. As 
a general rule, the more severe the injury produced in the tissue, the 
greater is the number which pass through. They cannot, like the white 
corpuscles, pass through by their own active movements, and, as far as 
can be seen under the microscope, they pass through actually intact 



INFLAMUA TION. 167 

vessels. It may be that from the dilatation of the vessels the stomata 
become so large that they are forced through by the increased pressure, 
or small fissures not visible under the microscope may take place by 
means of which they make their escape. When in the tissues they 
appear to take no active part in the changes which are going on. In 
part they find their way into the lymph-spaces and lymph-vessels, and 
are removed by the lymph-stream. In part they are taken up by other 
cells, and may contribute to the nutrition of these. In part they 
remain in the tissue and are destroyed, their pigment being taken up 
by the cells. 

The general character of the swelling differs greatly, depending on 
the anatomical structure of the part of the body which is inflamed. The 
so-called parenchymatous organs — as, for instance, muscle, kidney, paro- 
tid and other glands — swell in toto when they are inflamed. The swell- 
ing is proportional to the degree of the exudation. It will be more 
considerable in organs which are surrounded by a capsule or membrane 
which is capable of distention than in those which are surrounded by a 
membrane incapable of distention. In parenchymatous organs the exu- 
dation is in the meshes of the interstitial connective tissue, because this 
tissue carries the blood-vessels and is more easily distended by fluid. 
In the inflammation of connective tissue the exudation accumulates in 
its meshes ; it infiltrates it. In a furuncle the exudation accumulates in 
the loose spaces of the subcutaneous tissue, and in meningitis it accu- 
mulates in the spaces of the pia-arachnoid. The same is seen in the 
substance of the cornea when it is inflamed, but on account of the 
slight distensibilit}' of this tissue the thickening in the beginning 
of the inflammation is not a very marked one, and the infiltration 
appears more as a cloudiness of the tissue due to an interference with 
its optical properties than as a swelling. In cartilage, in which there 
are no distensible meshes or canals, the exudation-fluid or corpuscles 
cannot enter into the tissue ; therefore in inflammation of the cartilage 
of joints the exudation is found in the cavity of the joint, except in the 
immediate periphery, where under certaiji circumstances a few corpuscles 
apparently eat their way directly into the tissue. When the wall of a 
large cavity is inflamed the inflammatory exudation accumulates in the 
cavity. That is the case in the serous membranes, also in the dura 
mater. In the inflammation of periosteum the exudation cannot accu- 
mulate in the dense tissues, but it presses in beneath the periosteum, ele- 
vating it from the bone. The inflammatory exudation always accu- 
mulates where it finds the least resistance ; thus in pneumonia it enters 
the alveoli of the lungs and fills up these, because it finds no place in the 
alveolar septa. In the same way, it is easily understood that in places 
where a dense covering prevents the exudation reaching the free surface 
this covering will be elevated in the form of a bladder or vesicle. This 
is seen in the example we have given in the inflammation of the peri- 
osteum, but a better example is given in the inflammation of the skin. 
In all forms of acute inflammation of the skin one of the most common 
of all phenomena is to find the epidermis over the inflamed area elevated 
in the form of a vesicle. In organs which freely communicate with the 
outside, and an open way is given for the exudation, it is simply poured 
out on the surface and escapes. This is the case with all mucous mem- 



168 SURGICAL PATHOLOGY. 

branes, because their epithelial covering is loose and does not hold the 
exudation within it as does the epidermis. In consequence of this a 
formation of vesicles does not take place, but the exudation passes 
freely through to the surface. This is also the case in the kidneys, 
where the exudation in part passes off in the urine and appears in the 
form of albumin. 

Inflammation has been divided into two varieties, depending upon 
the special involvement of certain elements of an organ. In a glandular 
organ we can recognize the secreting cells and the connective-tissue 
framework supporting the cells and carrying the blood-vessels. Accord- 
ing as the special seat of the inflammation was supposed to involve the 
specific glandular cells, the parenchyma, or the interstitial tissue, the 
division has been made of parenchymatous and interstitial inflamma- 
tion. This division is a false one. If we regard inflammation as the 
sum of the processes which take place in the tissues on receipt of an 
injury, it is obvious that we cannot have inflammations so divided. It 
is hardly possible to conceive of an injury which will affect exclusively 
one or the other of these constituents of an organ. There is no doubt 
that under certain circumstances there may be accumulations of cells in 
the interstices of an organ due to growth of the intercellular tissue, as 
in some of the pathological conditions met with in the kidneys in scarlet 
fever. It cannot be held that all growth in connective tissue is due to 
regeneration following a primary lesion. In such kidneys there are few 
or no lesions of the epithelium of the tubules. In certain liver diseases 
a similar proliferation of the connective tissue may take place. We have 
generally been accustomed to speak of such conditions, in which we find 
a cellular infiltration of the tissue, as inflammation, but there is no reason 
why they should be so considered. The proliferation of the connective 
tissue may be due to the direct action of bacteria or their chemical prod- 
ucts on the tissue, or to other influences producing it without any pre- 
ceding injury. 

Inflammation of a mucous membrane is spoken of as "catarrhal 
inflammation." Virchow used the name to denote increase of func- 
tional activity of a mucous surface. The word " catarrhal " is used so 
loosely that it is difficult to define it. We may use it to designate mild 
degrees of inflammation of mucous surfaces in which there is neither 
ulceration nor any distinctly characteristic exudation, such as a fibrinous 
or a purulent one. In inflammation of the intestinal canal the word 
is generally used to include inflammations the etiology of which is un- 
known. The increased amount of fluid which comes from an inflamed 
mucous surface has two sources. In the first place, the mucous mem- 
brane has not a dense tissue on the surface impervious to fluids, like the 
horny layers of the skin, and an increased amount of exudation in the 
subcutaneous tissue readily finds its way to the surface instead of accu- 
mulating in the interstices of the tissues. A mucous surface is like a 
serous surface in this respect. In the next place, the proper secretion 
of the mucous surface is increased. This is in part due to the hyper- 
semia of vessels supplying the glands, and possibly in part to a direct 
stimulation of the glands by the inflanunatory cause. The cells may be 
influenced to increased action in the same way as the blood-vessels 
are. In most cases the serous exudation from the vessels of the tissue 



INFLAMMATION. 169 

is accompanied by emigration, and the leucocytes pass as readily through 
the epithelial layer as does the serum, and appear in the fluid on the 
surface. 

A more suitable classification of inflammation is one based on the 
character of the exudation. The character of the exudation is largely 
determined by the cause of the inflammation and the intensity of its 
action. The causes are so manifold that it would be impossible to give 
an etiological classification. The exudation in inflammation may be 
almost entirely serous, and such inflammations are spoken of as cedema- 
tous or serous inflammations. In any inflammation the quantity of serous 
exudation is increased. The tissue in serous inflammation is infiltrated 
with fluid. The increased transudation represents the reaction of the 
tissue to a mild injury. One of the best examples of it is the inflam- 
mation of the skin which follows prolonged exposure to the sun. The 
injection of the vessels is extreme and the skin is swollen and pits on 
pressure. Most of the exudation accumulates in the meshes of the 
tissue, but a certain portion passes to the surface and elevates the epider- 
mis in the form of smaller or larger vesicles. The vesicles are filled 
with a clear transparent fluid which on microscopic examination shows 
few cellular elements. If the cause be removed, the contents of the 
vesicles will be absorbed. The action of the sun has probably been to 
produce slight injury of the upper layers of the epidermis, in some cases 
extending more or less deeply into the tissues below. In some cases 
extensive necroses extending through the skin, which are followed by 
all the phenomena of intense inflammation, may be produced. There is 
increased serous transudation in the beginning of every inflammation. 
In pneumonia, congestion and oedema of the lung precede the formation 
of the fibrinous exudation. In every wound a clear fluid first exudes 
which contains but few corpuscles, and which, coagulating in a thin 
layer on the surface, produces the glazing. The cedematous inflammation 
may also represent the end or limit of the process. In a furuncle, out- 
side of the central necrosis and leucocytic infiltration, the tissues are 
infiltrated with serous fluid, and a subcutaneous oedema is often found 
accompanying acute inflammation of the costal pleura. 

In any inflammation there is an increased amount of fibrin in the 
exudation as compared with the normal (Fig. 5). The fluid in the tissue 
in oedematous inflammation contains more fibrin than when the exudation 
is increased from some other cause, as from chronic passive congestion. 
The fibrin may accumulate in the tissue and give rise to a dense, brawny 
induration. The amount of fibrin is to a certain extent dependent upon 
the severity of the inflammatory cause of the injury. As a general 
rule, the greater the degree of necrosis the more extensive will be the 
formation of fibrin. The elements for the formation of fibrin are 
present in the exudation, and the necrotic cells supply the fibrin-ferment. 
To a much greater extent the formation of fibrin seems to depend upon the 
nature of the agent which produces the inflammation. The most typical 
fibrinous inflammation is seen in acute croupous pneumonia. Even in 
the rabbit, when inoculated subcutaneously with the organism which 
causes this disease, a fibrinous exudation may be produced which 
may extend over the centre of the abdomen. It is possible that sub- 
stances may be produced by these organisms which have an analogous 



170 SURGICAL PATHOLOGY. 

action to the fibrin-ferment. Such inflammations, characterized by an 
excessive amount of fibrin in the exudation, are spoken of as fibrinous 
inflammations. The term is more generally used to specially character- 
ize fibrinous exudations on surfaces of the body. Such exudations are 
always accompanied by necroses, and are called diphtheritic. Formerly 
a distinction was made between croupous and diphtheritic inflamma- 
tions. In the croupous inflammations the exudation was supposed to 
be seated on the surface of relatively intact mucous membranes. In 
the diphtheritic inflammations the exudation was supposed to extend 
from the surface into the meshes of the tissue. The croupous exudation 
could be peeled as a membrane from the surface, leaving it intact ; the 
diphtheritic could not be removed without the production of a loss of 
substance. The only difierence between the processes is one due to the 
anatomical character of the surface. In both cases there is necrosis of the 
surface epithelium, and the exudation, coming in contact with the necrotic 
tissue which furnishes an abundent supply of fibrin-ferment, coagulates. 
The exudation can be easily removed as a membrane on surfaces having 
a dense basal membrane beneath the epithelium. It is not removed 
from the surface of the epithelium, but is removed with the epithe- 
lium. The exudation cannot be removed from the surface where there 
is no basal membrane beneath the epithelium, in which case the union 
of the epithelium with the tissues beneath is more direct. In this case 
the fibrin also extends down into the tissue beneath, and there is a close 
union with the fibrin on the surface and that in the tissues, and it cannot 
be removed as a mass. The difference between the two is easily seen in 
diphtheria. When the disease is localized in the pharynx the membrane 
cannot be removed. If in the larynx and trachea, it can be removed, 
sometimes representing a perfect cast of these parts. The term " diph- 
theritic inflammation " is simply an anatomical one, and has no necessary 
relation to the infectious disease diphtheria. This disease is charac- 
terized by a fibrinous exudation on the surfaces affected, combined 
with necrosis. It is very probable that here, just as in the fibrinous 
exudation in pneumonia, the character of the exudation is due in great 
part to the specific agents which cause the disease. In some cases the 
membrane is much more extensive than in others, and it may be pro- 
duced, though generally not to the same degree, by other agents than the 
diphtheria bacilli. Inflammations of the same parts caused by some of 
the pus-organisms, and even by the application of chemical agents which 
will produce a necrosis on the surface, may be accompanied by mem- 
brane-formation. The fibrin on the surface does not come exclusively 
from the exudation. The epithelium itself undergoes a form of necrosis 
which is combined with coagulation of the protoplasm of the cell, and a 
reticular mass is formed largely composed of the fibrinoid metamorphosis 
of the cells. The fibrin in these exudations does not always have the 
same character. In the tissues the fibrin usually appears in the form of 
extremely fine filaments. On the surface it may appear in the form of 
large hyaline masses or as a definite reticulum. In all of the mucous 
surfaces this form of inflammation is frequently observed. In the large 
intestines it forms one of the anatomical varieties of dysentery. On 
open wounds a fibrinous inflammation leading to the production of dense 
membranes is not infrequently observed. It may be due to infection of 



INFLAMMA TION. 171 

the wound with certain specific micro-organisms. In cases of diphtheria 
any open wound of the body is liable to become infected with the organ- 
isms of the disease, and a typical membrane may be formed over the 
wound. I have seen two cases in which the infection of wounded sur- 
faces resulted from accidental inoculation. In one there was a fissure of 
the anus which became so infected, and in the other a paronychia about 
the small toe became infected. In both the characteristic organisms were 
obtained from cultures. In the uterus a diphtheritic membrane with 
extensive necrosis of the surface forms one of the lesions found in puer- 
peral infection. Here the condition is in nearly all cases due to the 
presence of one of the pus-organisms, the streptococcus. Fibrinous in- 
flammations are also found on the serous surfaces, and they seem to take 
place more readily here than in any other part of the body. The fibrin 
is deposited both on the surface covering the viscera contained in the 
cavity and on that lining the walls. Where these two surfaces move over 
one another, as in the pericardium, the con3tant adhesion and separation 
give rise to a roughening of the surface, causing the appearance which 
has been compared with that produced by the separation of two pieces 
of bread and butter. In serous membranes the fibrinous inflammation 
is in part due to a greater degree of intensity in the action of whatever 
produces the inflammation. The same agent acting in different degrees 
of strength can at one time produce a simple serous exudation and at 
another a fibrinous exudation. When two surfaces covered with a 
fibrinous exudation come in contact with one another, adhesions are 
formed from the intermingling of the fibrillse of fibrin on the two sur- 
faces. In fibrinous inflammation of the peritoneum the adjacent surfaces 
of the viscera become adherent. The fibrinous exudation sometimes 
serves in this way a useful purpose in uniting wounds. The primary 
adhesion of a simple wound is due to this intermingling of the exudation 
from the opposing sides of the wound. 

Hemorrhagic inflammation is spoken of when the exudation contains 
large numbers of red blood-corpuscles. This character of inflammation 
may be due to a specific action of some agent producing the inflamma- 
tion, or it is due to constitutional anomalies on the part of the individual. 
Thus in scurvy and purpura an inflammation which under ordinary cir- 
cumstances would be serous only, may become hemorrhagic. The con- 
stitutional anomaly is due either to a condition of the blood-vessels which 
allows the red blood-corpuscles to pass through them more readily or 
possibly to changes in the blood itself. 



Purulent Inflammation. 

This is a form of inflammation which is sharply separated from the 
others, and is characterized by an exudation which is called pus. In 
other forms of inflammation the exudations may difler, depending upon 
the action of different causes or upon a greater or less intensity in the 
action of the same cause. We can have from the same cause acting in 
varying degrees of intensity a serous, a fibrinous, or a hemorrhagic 
exudation. By subjecting the ear of a rabbit to water at different 
degrees of temperature all the various forms of inflammation may be 



172 SURGICAL PATHOLOGY. 

produced, Avith the exception of the purulent. This cannot be produced 
by the action of the most intense caustics. 

Pus is a whitish or grayish opaque fluid of varying degrees of density. 
It may acquire a reddish tinge from an admixture of red corpuscles ; in 
some cases it has a distinctly yellowish or bluish tinge, the latter being 
due to certain of the bacteria which cause suppuration. The exudation 
may infiltrate in the tissues — that is, it may be contained in the meshes 
of the tissues, as in the serous exudation — or it may be contained in 
cavities which are hollowed out in the tissues. Such a cavity containing 
pus is called an abscess. Or, again, there may be a loss of substance on 
the surface from which such a fluid exudes. In all other forms of 
inflammation, particularly in the more severe forms, there is more or less 
fibrin in the exudation. In the purulent inflammation the exudation 
contains either no fibrin at all or only a small amount of it. Moreover, 
the exudation differs in the effect which it has on the tissues of the 
inflamed part. In the serous and fibrinous inflammations the exudation 
either accumulates in the interstices of the tissue, or, if it cannot be con- 
tained in this, it passes to the surface or into the natural cavities of the 
body, always following the path of least resistance. The exudation in 
itself seems to produce no injury to the tissue. The tissue, of course, 
may be injured by having its nutrition interfered with by compression 
of vessels produced by the exudation, and very extensive necrosis may 
be produced in this way ; but the exudation in itself produces no injurious 
action on the tissues with which it comes in contact. The purulent 
inflammation is different. In this there is not only destruction of cells 
by the exudation surrounding them, but the intercellular substance itself 
is destroyed and dissolved by the exudation. The exudation and the 
softening and destruction of the tissue combine to form the abscess. The 
dissolution of the intercellular substance takes place more easily in the 
loose areolar tissue. Not only is this solvent action of the exudation 
exerted on the intercellular substance, but the fibrin also, when any is 
present, is dissolved in it. 

We can easily follow the course of development of an abscess by 
injecting some of the bacteria, which from their specific action are 
spoken of as the pus-organisms, into the ear-vein of a rabbit. The 
organisms are carried into various tissues, and by their growth form 
small masses in these. The first effect of the presence of the organisms 
is the production of necrosis in the tissue immediately surrounding them. 
This is accompanied by an enormous emigration of leucocytes extending 
into the necrotic tissue, and the leucocytes to a great extent undergo the 
same necrosis as the tissue. In the periphery they form a more or less 
distinct Avail around the necrotic tissue. In the necrotic area itself there 
is of course no inflammation. Not only are the cells destroyed, but the 
blood-vessels as well, and no circulation takes place within the part. The 
next stage in the formation of the abscess is the liquefaction of the tissue. 
The bacteria or their chemical products appear to exert an actual dissolv- 
ing power on the tissue. First, apparently, the intercellular substance is 
dissolved, and all of the cells, both those of the tissue and the leucocytes, 
come together to form a single mass. Sometimes the tissue-cells more or 
less retain their form and can be recognized, but more often they are 
broken up into fragments or granules. In some cases the suppuration 



INFLAMMA TION. 



173 



does not spread from a single point in this way, but from several adjacent 
points. Then the various foci of softening come together, forming a single 
cavity, which may contain not only the nidividual cells which have been 
set free by the dissolution of the intercellular substance, but larger 
masses of tissue into which the softening has not fully extended, and 
which are set free by the various foci of softening meeting one another. 
The various tissues show a varying resistance to this softening power of 
the exudation. In a glandular organ the connective-tissue septa in the 
gland oifer the least resistance. The suppuration' may extend along 
these, and an abscess be formed which will contain large necrotic masses 
of the glandular substance. Such masses are spoken of as sloughs. 

The pus varies in consistence. Sometimes it is thick and creamy, at 
others it is thin and similar to a serous exudation. The cells are to a 
large extent the white corpuscles of the blood. Of course along with 
these cells there will be other cells and fragments of cells which come 
from the tissues. When the pus-cells are examined on the warm stage 
of a microscope many of them show active amoeboid movements. The 
fluid portion of the pus is simply the serous exudation. The pus con- 
tained in a definite abscess-cavity is frequently under considerable ten- 
sion, sometimes apparently much higher than the blood-pressure. On 

Fig. 6. 




Section of a chronic abscess of the lung : a, layer of granular material composed of necrotic cells 
and bacteria ; b, layer of tissue filled with leucocytes ; c, loose granulation tissue containing 
dilated blood-vessels, from which active emigration is taking place; d, denser cicatricial 
tissue. 



making an incision into an abscess the contents may spurt to a consider- 
able distance. When the abscess-cavity has remained for some time a 
definite wall is formed around it, which prevents its further extension 
(Fig. 6). As the abscess is forming there is constantly going on outside 
of the necrosis and outside of the wall of leucocytes a growth of the 
tissue. All of the cells of the tissue, the connective-tissue cells, those 
forming the walls of the blood-vessels, and probably also the specific 
cells of the tissue, proliferate. In consequence of this proliferation 
there is produced a dense tissue consisting to a large extent of cells 



174 SURGICAL PATHOLOGY. 

similar to the lymphoid cells of the blood. This is the same tissue 
which forms the small projecting granules seen on the surface of an 
ulcer, and from this it has received the general name of granulation 
tissue. Sometimes softening does not take place until such a definite 
wall is formed around the focus. This action on the part of the tissue 
varies in different cases. Sometimes it is almost entirely absent, and 
there is nothing opposed to the extension of the process. In some cases 
it would appear as though there were a direct excitation of cell-prolifer- 
ation of the tissues produced by the bacteria. Such a membrane lining 
an abscess is called a " pyogenic membrane." It is a soft reddish mem- 
brane having a slight similarity to a mucous surface. It was formerly 
supposed that pus could be directly secreted by such a membrane. It 
always contains, along with the cells derived from the tissue, a large 
number of leucocytes, which are constantly passing through it into the 
abscess, and in the vessels not only of the membrane itself, but in those 
of the surrounding tissues, there are quantities of leucocytes. In many 
cases the membrane does not offer sufficient opposition to the advance of 
the suppurative process. The cells composing it may become necrotic, 
soften, and form part of the contents of the abscess, and its formation 
gradually recedes as it is gradually destroyed. There is no sharp limit 
to the membrane-formation, but it gradually fades off into the surround- 
ing tissues. For a considerable distance around, the formation of gran- 
ulation tissue continues, appearing as an infiltration of the interstitial 
tissue with small round cells. Sometimes the purulent inflammation is 
preceded by a fibrinous or serous inflammation. The fibrinous inflam- 
mation of a serous surface may become changed into a purulent, and the 
fibrin which has been formed becomes dissolved in the pus. There may 
be a large amount of fibrin in the tissue surrounding an abscess which 
may become softened by the advance of the suppuration. 

We may distinguish various sorts of abscesses, depending on the cha- 
racter of the pus and the character of the tissue in which it is formed. 
When an abscess forms rapidly and is accompanied by a considerable 
amount of pain and evidences of acute inflammation, it is spoken of as 
an acute or a hot abscess. On the other hand, the abscess-formation 
may take place slowly, the pus may accumulate slowly, and, if this 
takes place in an organ poorly supplied with nerves, it may not give 
rise to any special symptoms. Again, the pus may be formed in one 
portion of the body, and may by gravity extend into a portion lower 
down, gradually dissolving the tissue as it passes along. Such an 
abscess is called a cold or gravity abscess. One of the best examples 
of this is the abscess which appears in the inguinal region, the pus 
being formed in the vertebrae and descending along the psoas muscle. 

The amount of pain in purulent inflammation differs greatly. In 
some cases it is intense; it others it may be entirely absent. This 
depends largely upon the character of the tissue and the amount of 
nerves in the part. In an abscess of the subcutaneous tissue, where 
pressure is exerted on the nerves of the skin, the pain may be intense. 
In abscesses in internal organs poorly supplied with nerves, as in the 
liver, a large abscess may be formed without any pain accompanying it. 
The pain will also, as in an ordinary inflammation, depend upon the 
amount of pressure which is exerted on the nerves. In a tissue capable 



INFLAMMATION. 175 

of distention there will be less pain than in a firm, dense tissue. Ab- 
scesses of bone and of the periosteum are accompanied by intense 
pain. The amount of pain will also depend upon the rapidity with 
which the abscess is formed. If the pus accumulates rapidly, the pain 
will be more intense ; if it accumulates slowly, the tissues can gradually 
become accustomed to the distention. 



Inflammation produced by Bacteria. 

The action of almost all pathogenic bacteria is closely related to 
inflammation, because such bacteria in general produce an injury to the 
tissue where they are present. The inflammations which are produced 
by bacteria are also in some ways different from the chemical or mechan- 
ical inflammations. Bacteria may act on the body in a variety of ways. 
In the first place, the organisms may enter directly into the blood, and 
there find suitable conditions for their growth, or, without growing 
in the blood, may be deposited by it in the different organs. In 
most cases there is a primary lesion produced, and the infection of 
the blood follows from this. In consequence of this the bacteria may 
be deposited in the various organs of the body, and foci similar in their 
general nature to the primary focus of infection may be formed. A 
distinction must be made between the cases in which the organisms grow 
in the blood and the cases in which they may enter the blood, but do not 
find there suitable conditions for their growth, and the blood simply acts 
as a carrier, depositing them in various organs, where they exert a local 
action. When the organisms enter into the blood the condition of septi- 
caemia is produced. Many of the pus-organisms have the power of infect- 
ing the blood, and septicaemia is most frequently found as an accompani- 
ment to some one of the purulent affections. In many cases the danger 
of septicaemia seems to stand in inverse relation to the extent of the pri- 
mary infection. The more developed the local infection, the less apt 
the septicaemia is to take place. Frequently the same organism which 
causes a typical local disease in one animal will produce septicaemia in 
another. In man inoculation with the anthrax bacillus will always 
produce an intense local inflammation at the point of inoculation, the 
anthrax pustule, M^hich is only exceptionally followed by septicaemia. 
Most of the local lesions produced by bacteria are distinctly inflamma- 
tory in character. This is eminently the case in most of the acute 
infectious diseases ; for instance, in anthrax, in diphtheria, in pneu- 
monia. Many of the inflammations so produced are purulent in cha- 
racter. In other cases lesions very closely related to inflammation, or 
which at some period of their course are accompanied by inflammation, 
will be produced. The lesions which are produced by the tubercle 
bacillus and by the typhoid bacillus are at first not inflammatory in 
character. The lesions consist in a new formation of tissue of a definite 
type, which arises from proliferation of the fixed cells of the tissue. In 
the beginning of these formations there may be no emigration of leuco- 
cytes and no inflammatory lesions in the tissue. At a later period, 
however, in each, necrosis and degeneration take place in this newly- 
formed tissue, and with this the inflammatory phenomena begin. In 
typhoid fever the lesions, in the first place, consist of a new formation 



176 SURGICAL PATHOLOGY. 

of lymphoid tissue arising from the lymphoid tissue of the intestinal 
canal. In this lymphoid tissue there are no leucocytes, and, although 
there may be hyperemia of the surrounding blood-vessels, there is no 
emigration of leucocytes and no increased exudation. It is only when 
necrosis takes place in the hyperplastic tissue that the invasion of leuco- 
cytes begins. The same is true in tubercle. Emigration only begins 
and leucocytes are only found in the tuberculous tissue when caseation 
appears. The necrosis which arises in a specific tissue in this way appar- 
ently has the same attraction for the leucocytes as has necrosis of 
normal tissue. The same thing is true of the new formations not caused 
by bacteria. Many of the tumors are accompanied by inflammation in 
the surrounding tissues, and even in the tumor itself there may be emi- 
gration, an increased exudation from the blood-vessels; and this is 
closely connected with processes of degeneration in the tumor. These 
processes may be related to inflammation in another way. Thus the 
tubercle may excite inflammation merely by its presence. It may pro- 
duce by its presence injuries in the tissue which will be followed by 
inflammation, and which may not be immediately connected with the 
bacteria. 

The character of the inflammations produced by bacteria will be 
largely influenced by the manner in which these gain entry into the 
system. This may take place in various ways. They maj^ enter into 
the tissues, producing an inflammation at the point at which they enter, 
or they may produce no local lesions at the point of entry, and be 
carried by the blood to various tissues of the body and deposited there, 
only producing lesions in the tissues for which they have a specific 
afiinity, which is probably due to the fact that certain tissues offer them 
the most suitable conditions for their growth. This is the case in small- 
pox and in scarlet fever. Although we do not know anything about 
the virus of small-pox or of scarlet fever, it is exceedingly improbable 
that the lesions of the disease could be produced by bacteria finding 
entry through the skin. The same bacteria do not always act in the same 
way. In general we are able to surmise from the character of an 
inflammation what is the specific organism which has caused it ; but 
there are exceptions to this. The same organism which causes a typical 
fibrinous inflammation in the lungs may under some circumstances 
produce a distinctly purulent inflammation without any formation of 
fibrin at all. One of the pus-organisms, the streptococcus, may pro- 
duce in the pharynx as typical a fibrinous inflammation as is produced 
by the diphtheritic bacillus, while under other conditions it may form 
an abscess. The bacteria may also be related to inflammation in 
another way. They may produce local lesions, and there may be 
produced in these local lesions chemical poisons which will produce 
necrosis and degeneration in distant organs, and these may be followed 
by inflammatory phenomena. The most typical inflammations are pro- 
duced by a group of organisms which are so closely related to suppuration 
that they are called the pyogenic or " pus-organisms." Suppuration may 
under certain circumstances also be produced by a number of other 
organisms. The essential pus-organisms are the staphylococcus aureus, 
the streptococcus pyogenes, the staphylococcus epidennidis albus, the 
bacillus pyogenes fostidus, and the bacillus pyocyaneus. In addition to 



INFLAMMATION. 177 

these suppuration has frequently been found to be produced by other 
organisms ; for instance, by the colon bacillus, by the tubercle bacillus, 
by the diplococcus lanceolatus, by the baeillus proteus, and by various 
others. The most typical purulent inflammations are those produced by 
the staphylococcus and the streptococcus. lA the case of the staphylo- 
coccus its action has been thoroughly investigated by experiments both 
on man and animals. The most typical inflammation in man produced 
by it is the ordinary boil or furuncle. In this it is evident that the 
bacteria find their way into the skin along the hair-follicles or the 
sebaceous glands. It has been found that the mere application of the 
organisms to the surface of the skin is not followed by any results. 
When they are rubbed into the skin the typical furuncle may be 
produced. They apparently do not enter into the skin by means of the 
sweat-glands, and furuncles do not appear on the parts of the body 
where there are no hair-follicles or sebaceous glands, as on the palm 
of the hands or the soles of the feet. They are most apt to appear on 
portions of the body which are subjected to the rubbing of clothing, as 
at the back of the neck and the waist-line. There is first produced a 
necrosis of the tissue in the neighborhood of the hair-follicles or gland, 
and around this suppuration. The necrotic tissue which produces this 
does not always liquefy, but remains as the so-called core of the 
furuncle which is cast out with the pus. The pus produced by the 
staphylococcus, as a rule, is thick and creamy, frequently with a 
distinctly yellowish color, probably due to the pigment produced by the 
organisms in their growth. The streptococcus has a greater variety in 
its action than the staphylococcus. The streptococcus may produce on 
the surface of mucous membranes a typical fibrinous exudation, or it 
may produce suppuration of the tissues. Its action, even in producing 
suppuration, is not circumscribed, as is the action of the staphylococcus. 
Typical suppuration with liquefaction of the tissues is not so apt to be 
produced, and the pus has not the thick creamy character of that of the 
staphylococcus. In many cases no suppuration at all is produced, but 
simply an infiltration of the tissue with serum and leucocytes. When 
suppuration is produced by the streptococcus pyogenes it usually takes the 
form of purulent infiltration. Streptococci may be found in the tissues 
even outside of the line of leucocytes, and they do not produce so much 
necrosis, nor do they themselves exert such a positive chemotaxis, as do 
the staphylococci. Both the streptococci and staphylococci may produce 
on serous surfaces extensive suppuration. On both serous and mucous 
surfaces the inflammation produced by the streptococci is accompanied 
by a greater formation of fibrin. The inflammations produced by the 
streptococci are, as a rule, far more dangerous in their local and in their 
general effects than those produced by the staphylococci. Inflammation 
of the uterus in puerperal fever is almost always due to the action of the 
streptococci. 

Inflammations produced by bacteria show in one way a vast differ- 
ence from those produced by the action of chemical and mechanical 
causes. In inflammation produced by mechanical causes the action of 
the cause ceases with the inflammation. It is impossible that it should 
extend to other parts of the body. The bacteria may be in various ways 
carried from one portion of the body to another, and wherever they 

Vol. I.— 12 



178 SURGICAL PATHOLOGY. 

come they produce the same character of inflammation as in the primary 
focus. Those inflammations which appear in the difierent portions of 
the body following a primary focus of inflammation are called second- 
ary or metastatic inflammations. The organisms may pass along the 
course of the lymphatics, either producing inflammations in places 
connected immediately with the primary focus by means of the lym- 
phatics, as the lymphatic glands, or they may be carried by the lymphatics 
into the blood and then into other organs. They are most apt to be 
retained in the nearest lymphatic glands and excite these to inflamma- 
tion and suppuration. As an example of this we have the buboes in 
the groin which follow local processes in the external genitals. The 
lymphatic glands may also be excited to inflammation by other products 
than the bacteria. The chemical products which are produced in the 
inflammatory focus are washed out by the exudation and carried by the 
lymphatics to the lymph-gland, where they may excite inflammation. 
Such inflammations are rarely followed by suppuration, and the changes 
in the gland more generally consist in hyperplasia and the formation of 
a new lymphoid tissue. 

When the organisms enter into the blood they are carried into all of 
the organs and tissues of the body. But there is a decided difierence in 
their action in the different tissues. Certain of the tissues are more 
liable to have these secondary abscesses following on blood-infection 
than others. When the staphylococcus aureus is injected into the ear- 
vein of a rabbit, the metastatic abscesses take place in different organs. 
The organisms of course first find their way into the blood-vessels of the 
lungs, but here it is extremely rare that we ever find any lesions pro- 
duced by them. The secondary foci of inflammation, the abscesses, are 
generally limited to the kidney and to the myocardium. They may also 
develop in the muscles of the body, but here, again, the preference is 
shown for certain regions. The muscles most frequently attacked are 
the abdominal muscles. It is difiicult to explain this. The frequency 
with which certain organs are attacked may be due in large part to 
special differences in the circulation of these organs. In both the 
kidney and the heart the arteries are terminal ; that is, each portion 
of the tissue is supplied by a distinct artery without anastomoses. The 
same condition obtains in the spleen and in the brain, but abscesses only 
rarely develop in these parts. It cannot be due to the greater facility 
with which the organisms are deposited in certain organs. All sorts of 
very finely-divided foreign bodies entering into the blood are deposited 
with greater facility in the liver than in any other organ, because here 
there is an enormous system of capillaries with very slow circulation. 
It is probable that the organisms find in the tissues of certain organs 
more favorable conditions for development than in others. The organ- 
isms appear to be rarely carried as large embolic masses plugging up 
blood-vessels. In the kidney there is little doubt but that they do act 
partly in this way, and the effect of their specific presence may be accom- 
panied by the mechanical effects of infarction. They are not carried as 
embolic masses, because, even if they were injected as such into the 
veins, they would not be able to pass through the blood-vessels of the 
pulmonary circulation. In the kidney their action has been closely 
studied by Ribbert. It is probable that they lodge in or are taken up 



INFLAMMATION. 179 

at some point in the circulation by the endothelial cells of the small 
arteries, and by their continuous growth they may plug up the vessel, 
and from this primary focus they may be carried as masses into smaller 
branches of the same artery. 

The secondary inflammation may be produced in another way. The 
bacteria may find entry into the tissue along various ducts or canals 
which lead from the primary focus into other portions of the body. 
The most typical example of this is given in the secondary abscesses 
which develop in the kidney following a primary purulent inflammation 
of the bladder or of the urethra. The organisms make their way from 
the bladder into the kidney in a direction opposed to the flow of the 
urine. It is probable that their progression is due to a gradual growth 
along the wall of the urethra and of the pelvis of the kidney. They 
may do this without producing any inflammation of the urethra, but 
most often there is a general inflammation of this ; or it may be that 
they find suitable conditions for growth in the urine in the urethra, and 
infection may follow in this way. Einne includes among the metastatic 
abscesses those produced by the action of bacteria which enter the body 
without producing any lesions at the point of entry, and are often carried 
into remote organs, where their action takes place. 

There is the greatest diversity in the effects produced by the pyogenic 
organisms. This is due to a number of factors, and, although much 
light has been thrown on the matter by experiments on animals, there 
remains much which is not at all or imperfectly understood. As a 
result of the entry of the same organism into the system there may be 
no effect produced ; or there may be a slight inflammation not leading to 
suppuration or more or less extensive abscess-formation ; or without 
definite abscess-formation an extensive and diffuse purulent infiltration 
of the connective tissue ; or without the production of any local lesions 
there may be a general infection of the blood, and death may take place 
in two or three days with the phenomena of an acute intoxication. I 
saw during the last year a case in which a surgeon died several days 
after an operation on a case of peritonitis. There was no history of a 
wound received at the time of operation, and no definite point of entry 
for the organisms could be found at the autopsy. The most extensive 
lesions were in the right thigh and extended from this up to the buttocks. 
Over these parts there were large blebs and partial desquamation of the 
epidermis. The subcutaneous tissue and the adjacent muscles were 
necrotic and contained masses of streptococci. The same organisms 
were obtained in pure culture from the blood and from every organ of 
the body. The infection very probably took place from the thigh, and 
the organisms possibly entered from a scratch with the nail or in some 
such way. There was no definite suppuration, and in the necrotic tissue 
of the muscle there were but few leucocytes. 

In any attempt to explain such variation in action the resistance of 
the tissue must be considered. This resistance is due to a number of 
things. The blood-serum is directly destructive to a number of organ- 
isms, and when they are subjected to its action, in some cases for a 
few hours only, they are destroyed. Also, there is no doubt that the 
leucocytes play a most important part in destroying the bacteria, in pre- 
venting their absorption, and in warding off their action from the sur- 



180 SURGICAL PATHOLOGY. 

rounding tissue-cells. It is probable that this action of the leucocytes 
is not the only way that the body has of combating the organisms, btit 
it plays an important part. Different animals have different degrees of 
susceptibility to the action of bacteria. It is probable that this is largely 
due to differences in the destructive powers of their serum. The number 
of organisms which are introduced into the body has an important influ- 
ence. This is shown by the results of the injection of _ the staphylo- 
coccus into the ear-vein of a rabbit. If the organisms injected are of 
the same degree of virulence, the effect produced is largely dependent 
upon the amount of the culture which is injected. Very small doses 
may produce no effects. The tissue into which the organisms are intro- 
duced is of importance. After the injection of the staphylococci into 
the ear-vein of a rabbit abscesses are developed in certain organs only, 
and this cannot be explained by the organisms entering these organs 
only, for other organs are equally exposed to their action. The same 
thing is seen in the direct injection of the organisms into the tissue. The 
smallest drop of a pure culture of the staphylococcus injected into the 
anterior chamber of the eye of a rabbit is sufficient to develop an exten- 
sive suppuration, with loss of the eye. A much greater quantity is neces- 
sary to produce an abscess when the injection is made into the loose 
subcutaneous tissue of the back than is required when the injection is 
made into the dense tissue of the ear or into the muscles. This is 
probably in part due to the greater ease of absorption in the several 
places. When the absorption is rapid the bacteria can be taken into 
the blood, and there be destroyed by the serum without time being given 
for their local action in producing necrosis of the tissue and chemical 
poisons. Grawitz has shown the importance of absorption in his work 
on the production of peritonitis in the dog. This animal possesses to a 
high degree immunity to the action of the staphylococcus. Large quan- 
tities of the organisms may be injected into the peritoneal cavity with- 
out any effect, provided the tissues are normal. If the power of absorp- 
tion be in any way interfered with, or if the serous surface be stripped 
off over a small area, general purulent peritonitis results. Halsted has 
shown that the same thing is true when, instead of a fluid culture, a 
piece of potato with a growth of the organism on its surface is placed 
in the cavity. In this case a fatal peritonitis is always produced. The 
potato has nothing to do with the result beyond affording a suitable place 
for the development of the organisms and allowing them to produce their 
chemical poisons. The potato without the organisms becomes rolled up 
in the omentum and encapsulated. If an emulsion of agar with the 
organisms growing in it be injected beneath the skin, it is more surely 
followed by suppuration than when the culture is injected in a fluid 
medium. One of the main elements seems to be the action of the sol- 
uble chemical poisons produced by the organisms. If the injection is 
made into a dense tissue, the organisms may find a suitable soil for their 
development, or they may create it by the production of necrosis in the 
surrounding tissue. The poison which they create may not only inhibit 
the local resistance of the tissue, but when it is gradually absorbed it 
may destroy the germicidal power of the entire blood-current. In any 
case it is of the utmost importance to oppose to the action of bacteria 
as normal tissues as possible. It is probable that a great deal of the 



INFLAMMATION. 181 

result of modern methods of surgical technique is due as much to the 
greater care bestowed upon wounds as to the care exercised in excluding 
bacteria. 

Differences in the virulence of the organisms play an important part 
in their effects on the tissues. The pus-organisms are not definite chem- 
ical compounds, and they vary enormously in their virulence. This 
virulence is gradually lost in the cultures. It remains longer in the 
staphylococci than in the streptococci. A few generations of cultures 
may suffice to destroy the virulence of the streptococci completely. In 
the staphylococcus aureus we can to some extent estimate the degree of 
virulence by the intensity of the color which is produced. The source 
from which the organisms are derived is also of importance, as is also 
the fact whether the organisms are injected alone or accompanied with 
toxic substances. The various accompanying toxic substances must play 
a great part in the purulent infections as they occur under natural con- 
ditions. In natural infection we have to do, not with pure cultures 
of the pyogenic cocci, but with organisms which have come from all 
sorts of sources and have been growing in various conditions, and 
which are frequently mixed with many kinds of bacteria. There is 
proof that under some of these conditions the infectious material 
may acquire a degree of virulence which we are not familiar with in 
artificial cultures. Bumm found that injection into the peritoneal 
cavity of a rabbit of a fraction of a drop of the fluid from a case of 
acute puerperal peritonitis produced acute peritonitis in the animal, 
whereas pure cultures of the same organism were nothing like so 
virulent. Fehleisen found that a pure culture of the staphyloeoceus 
aureus to which he had added a little of the clear fluid from the 
inflammatory oedema of a spreading cellulitis was far more virulent 
than the ordinary culture. 

Any condition of the system which lowers its general resistance will 
increase the action of the pus-organisms. It has been found that sup- 
puration is more easily excited and is more intense in animals which 
have been rendered anaemic. Even when local anaemia is produced by 
tying or constricting an artery, the suppuration following inoculation 
with the same amounts of the organisms is more severe on the anaemic 
side than on the normal. If the blood is rendered hydraemic, the effects 
of inoculation are increased.^ 

Some of the infectious diseases render the tissues more liable to the 
effects of the pyogenic organisms. This has been shown in typhoid 
fever. An old focus of inflammation may become purulent when the 
resistance of the tissues is lowered by disease. Not only may the gen- 
eral resistance of the body be overcome, but the local resistance as well. 
Various local injuries of the tissues have been produced, and then organ- 
isms injected into the circulation, and it has been shown that in many 
cases the organisms have settled in the injured tissues and have there 
produced a purulent inflammation. Sometimes the presence of other 
bacteria increases the action of the pus-organisms. Trombetta has 
shown that when cultures of the staphylococcus were mixed with the 
prodigiosus the effects were increased. The tubercle bacilli and the 
typhoid and other organisms when mixed with the staphylococci have 

'■ Welch : Conditions underlying the infection of wounds. 



182 SURGICAL PATHOLOGY. 

the same effect. The resistance of the tissues is undoubtedly lowered 
when chemical products of the bacteria are introduced along with them. 
In any case it is probable that the diminished resistance of the tissues is 
due to changes in the blood, and consists chiefly in destruction or diminu- 
tion of the germicidal power. The presence of such chemical products 
of bacteria may also prevent the establishment of leucocytosis. While 
it is probable that in man the injection of even a large number of pus- 
organisms in the normal blood would have little or no effect, the con- 
dition is different when the organisms enter into the blood after its 
germicidal power has been weakened by absorption of poisons from the 
local suppuration. Metastatic abscesses do not develop early in the course 
of a suppuration, but at a late period when the blood has been poisoned 
by absorption. They are not due alone to the organisms. Even dead 
organisms when injected into the tissues in sufficient quantities may 
excite suppuration, for the protoplasm of the dead bacteria is a powerful 
agent in attracting the leucocytes. 

In speaking of suppuration, so far, we have only considered it in 
relation to the bacteria. For all practical purposes that is the only way 
in which it need be considered. All of the suppurative processes which 
we meet with in man are due to bacteria, and they may be obtained 
either in cultures made from the pus or on microscopic examination of 
the tissues. If the cultures made from an abscess are sterile, that is no 
proof that the suppuration was not produced by bacteria. The organisms 
may be dead or they may not grow on the medium which was used for 
culture. Other organisms than the bacteria may excite suppuration. It 
is known that some of the protozoa have this action. The amoeba coli 
when it enters into the liver from the large intestine will produce 
abscesses, and it has been found to be the cause of abscess-formation 
in other places. Flexner has reported a case in which an abscess of the 
jaw was produced by this organism. 

It is certain that typical suppuration may be produced by chemical 
substances, but abscesses so produced are not often met with. There 
has been a great deal of experimenting done on this question, and it 
may be regarded as established in the affirmative. Croton oil is one 
of the most certain substances to produce suppuration when injected into 
the tissues. In a series of experiments croton oil was enclosed in thin 
glass capsules which were previously thoroughly sterilized. These were 
placed beneath the skin of rabbits, and after several days, in every case 
after the wound was thoroughly healed, they were broken from without. 
In every case a typical focus of suppuration was produced. It has long 
been known that when croton oil is rubbed into the skin a crop of small 
pustules will result. Turpentine and a few other substances will pro- 
duce suppuration, but not so certainly as will croton oil. There is no 
reason why some of these substances may not do this. They are caustics, 
and when they come in contact with the tissues they will produce necro- 
sis ; and they probably have in themselves, or they assist in forming in 
the tissues, substances which have the power of dissolving the necrotic 
tissue and the fibrin. 

Not only the purulent inflammations, but inflammations of any sort, 
are affected by the condition of the body, and especially by local or gen- 
eral pathological conditions of the circulation. For the preservation of 



INFLAMMATION. 183 

the normal condition of the tissues a normal circulation is necessary. The 
blood must flow through the tissues in the proper amount, with the 
proper pressure, and the quality of the blood must not be altered. A 
change in any one of these conditions or all of them has an important 
influence in modifying the course of inflammation. We have already 
spoken somewhat of the influence of anaemia in modifying the purulent 
inflammation. When the central artery of the ear of a rabbit is ligated, 
sufficient blood will enter the ear by the small arteries on the edge of 
the ear to preserve the integrity of the tissues. If, however, after liga- 
ting the central artery the ear be exposed to influences which in normal 
circulation would result only in a minor degree of inflammation, a much 
more severe type, frequently ending in necrosis of the entire tissue, will 
be produced. Samuel has shown that the exposure of the ligated ear to 
water at a temperature which would only slightly affect the part in a 
normal circulation will be followed by necrosis. In a more extensive 
series of experiments in parts subjected to various degrees of vascular 
disturbances he found that in anaemic parts all the phenomena of inflam- 
mation developed more slowly and ran their course in a much longer 
time. The congestion of the tissues comes on more slowly, is more 
extensive, and there is a tendency to coagulation of the blood in the 
dilated vessels, producing complete cessation of the circulation. 

The course of inflammation is also modified by active arterial hyper- 
semia. Danilewski first studied this by exposing both ears of a rabbit 
to the same injurious influence after section of the sympathetic on one 
side. He found there was a marked difference in the course of inflam- 
mation in the hypersemic ear as compared with the other, and the pro- 
cess took a more rapid and ran a more favorable course. He, however, 
made the mistake of regarding the ear not operated on as being in a 
normal condition. It is now known that after section of the sympathetic 
the hypersemia of the ear on the side which is cut is accompanied by 
anaemia of the ear on the uninjured side ; so that he really compared 
inflammation in a hypersemic part with inflammation in a somewhat 
anaemic part. Samuel afterward studied the same subject more carefully, 
and found that in a hyperaemic part a more severe type of inflammation 
followed the same degree of injury and lasted longer. The exudation 
is more abundant, the swelling is greater, and all of the phenomena are 
more active. After the inflammatory dilatation of the artery it does 
not so quickly return to the normal calibre in the hyperaemic ear as 
in the normal. 

Still more unfavorable are the conditions when inflammation takes 
place in a part in which there is chronic congestion. Here the quantity 
of the blood is increased, but, owing to the slowness of the circulation, 
the tissues are placed in an abnormal condition. The part can, as in the 
anaemic part, preserve its integrity under the ordinary conditions of life, 
but slight influences will be more easily felt. The blood flows more 
slowly through the part, the blood-vessels themselves are dilated, and 
the tissue lives on a lower plane. Its reserve force, its capacity for 
repair, is diminished. Not only will a slight cause produce a more 
severe type of inflammation, but the inflammation will run a much 
longer course and repair take place more slowly. Inflammation of this 
character is spoken of as hypostatic inflammation, and a good example 



184 SURGICAL PATHOLOGY. 

of it is seen in the inflammation of the posterior part of the lung which 
comes on in the course of various diseases when the patient has lain for 
a long time on the back. The ordinar}'^ effects of hypostasis in such 
cases are increased by weakness of the circulation due to diminished 
force of the heart's contraction, and the blood itself is also altered. The 
cause of the inflammation in such cases is usually the stagnating secretion 
of the bronchi, in which infection may take place. 

Another example is seen in the inflammation of the leg in chronic 
passive congestion due to local or general impairment of the circulation. 
In this condition a slight blow or other form of injury which would not 
be felt, or only slightly, under normal conditions, will be followed by 
extensive inflammation, which may not heal until the part be placed in a 
condition more nearly approaching normal. This can be done by eleva- 
ting the leg and removing the influence of gravity. 

Not only will purulent inflammation take place more readily, but any 
inflammation will run a more severe course in a person who is the sub- 
ject of general anamia. Other conditions — as diabetes, for instance — 
have a marked influence on inflammation. In diabetes the inflammation 
tends to assume a necrotic character. It is probable that in diabetes the 
germicidal powers of the blood-serum are greatly diminished. Infec- 
tion with the pus-organisms takes place more readily and is more severe. 
The primary cause of inflammation being injury to the tissue, however 
brought about, we can see that a tissue placed in an abnormal condition 
cannot so easily guard against an injury, and a slight cause will be fol- 
lowed by a greater effect. The inflammation will persist until the integ- 
rity of the tissue is restored, and this will take longer when the condi- 
tions for the nutrition of the tissues are not so favorable. Sometimes 
a tendency to certain sorts of inflammation seems to be inherited. In 
some persons, even when the circulation and nutrition seem to be per- 
fectly normal, inflammation is more easily excited in certain organs 
and takes a more severe course. Thus an individual may be predis- 
posed to inflammation of the air-passages and other parts of the body. 
In this case it is not the inflammation itself which is inherited, but a 
weakness or lack of resistance of the body. What this is we are unable 
to define. It may be, as Cohnheim suggests, an abnormal condition of 
the blood-vessels of the part. It seems in many cases to be local and 
not general. In some cases there appears to be a general weakness of 
the tissues inherited. There may be an inherited lack of resistance to 
certain causes of inflammation or to inflammation generally. Individ- 
uals with an inherited tendency to tuberculosis frequently show a 
general lack of resistance to all sorts of inflammatory causes. 

Repeated attacks of inflammation in the same part render it more 
liable to inflammation. This is due to an abnormal condition of the 
part caused by the repeated attacks of inflammation. At each attack of 
inflammation the tissue may not be completely restored, and finally an 
abnormal tissue, one of lower resistance, is established. The tissue is 
then placed in the same condition as when subject to anasmia or any 
other disturbing influence. It can only preserve its normal condition 
under ordinary circumstances. The tissues are more vulnerable, and a 
cause which would not be felt in a normal tissue may produce a degree 
of injury in this which cannot be overcome without inflammation. 



INFLAMMATION. 185 

It is not necessary to consider at great length the differences between 
acute and chronic iniiammation. The phenomena of inflammation vary 
in duration and last until the tissue is brought to a normal state. In 
general, the difference is due to the length of time that the cause of inflam- 
mation continues. A sudden injury of the tissue, in which the cause is 
removed as soon as the injury is effected, is followed by active inflam- 
matory phenomena, which will also subside when the cause — that is, the 
injury which has been produced on the tissues — is removed. In some 
cases the injury may take place more slowly, and the injurious agent, 
whatever its character, may act continously, and the phenomena of inflam- 
mation develop more slowly and continue for a longer time. In these 
cases we have the process of repair, the attempt of the tissues to return 
to a normal condition, going on at the same time that the injurious cause 
is still acting, and the phenomena which we are accustomed to regard as 
typical of inflammation — i. e. heat, redness, swelling, and pain — develop 
so slowly or may be so slight as to escape our attention entirely. These 
chronic inflammations are frequently due to bacteria, which may extend 
their action not only to the tissues into which they first enter, but may 
continously affect the new tissue which is produced in the repair. 

Another variety of inflammation is the so-called trophic inflammation 
supposed to be due to trophic disturbances. It is assumed by those 
believing in this that there is a direct nervous influence acting on the 
nutrition of the tissues, independent of the influence of the vasomotor 
nerves. The nutrition of each cell is supposed to be directly influenced 
by the nervous system, and the nerves governing this nutrition are spoken 
of as trophic nerves. Physiologists in general and pathologists do not 
believe much in this, and the arguments advanced in favor of the view 
have generally come from clinicians. As an example of such so-called 
trophic inflammations we may cite the inflammation of the cornea which 
follows section of the trigeminus. Magendie first observed that after 
section of this nerve inflammation of the cornea, with ulceration and 
destruction of the entire eye, generally takes place. There may also be 
inflammation of the lips and other parts supplied by this nerve. It has 
been also observed that after section of the pneumogastric pneumonia, 
frequently terminating in gangrene, develops. Another example of 
trophic inflammation is found in the perforating ulcer of the foot which 
develops in certain diseases of the spinal cord. In most cases a definite 
proof has been given by experiments that these inflammations do not 
take place when other injurious influences resulting from the section of 
the nerve are excluded. The inflammation of the cornea after section of 
the trigeminus is the result of the action of particles of dust and other 
foreign substances which the eye in its anaesthetic condition is no longer 
able to guard against. It is possible to remove the effect of the action 
of such traumatic influences on the cornea by sewing the edges of the lids 
together or by fastening one of the animal's ears over it. Von Gudden 
took newly-born rabbits and sewed the edges of the lids together, pro- 
ducing a perfect union. After the Avounds were healed and the eyes 
absolutely sealed he cut the nerves, and on opening the eyes fifteen days 
after the nerve-section he invariably found the cornea normal. The 
inflammation of the lungs which follows section of the pneumogastric is 
due to the presence of particles of food and other foreign substances 



J 86 SURGICAL PATHOLOGY. 

which have been aspirated into the bronchi. Paralysis of the glottis is 
produced by the experiment, and the most simple way of preventing 
inflammation is to keep the animal experimented on in the dorsal position 
and thus prevent foreign substances entering into the glottis. Such lesions 
as perforating ulcer of the foot and the various joint diseases which occur 
in the course of certain diseases of the spinal cord are extremely rare in 
patients whose circumstances enable them to avoid over-exertion in the 
later stages of the disease and to observe every needed care. It is easy 
to see how this idea of trophic inflammation may have arisen. The 
tissues are placed in an abnormal condition. Not only is there anaesthesia 
of the tissue, but the circulation in the part is more or less disturbed. 
Thus, in paralysis, extensive ulceration (the so-called bed-sore) is fre- 
quently developed over the sacrum and other prominent bony eminences. 
This is due to a variety of conditions — to the ansemia which is produced 
by pressure and to the action of the urine and faeces which are frequently 
involuntarily passed by the patients, and unless the greatest care is exer- 
cised the parts in question come in continuous contact with them. The 
epidermis over the part will be macerated ofi^, and the tissue beneath, 
whose vitality is already impaired, will be exposed. In consequence of all 
of these conditions the tissue becomes necrotic and large ulcers will form. 
Such bed-sores can always be prevented by proper care and cleanliness, 
and in general we may regard them as due not to trophic disturbances, 
but to bad nursing. Cystitis until comparatively recently was considered 
to be one of the symptoms of inflammation and of injury to the spinal 
cord. It is now regarded as a complication easily prevented by the use 
of clean catheters introduced with care. 

There seems to be much more proof in favor of regarding some of the 
herpetic affections as due to trophic influences. These develop in the 
skin over the area supplied by certain nerves, and it has been found in 
some cases that the nerves or the ganglia from which they arise are 
inflamed. Samuel suggests the possibility that these inflammations may 
be due to an intense hypersemia of the part brought about by the paralysis 
of the vasomotor nerves. Strfimpel suggests the probability that the 
inflammation in herpes zoster may be infectious and due to a definite 
cause. One argument in favor of this is the frequent appearance of 
herpes zoster in an epidemic or endemic form. Pfeiffer thinks that in 
these cases the inflammation should be regarded as an infection which 
follows along the course of the intercostal nerves. The nutrition of 
parts is undoubtedly affected by nervous influences, and integrity of the 
nerves is necessary to keep the tissue in a normal condition. No part 
receives continually the same supply of blood, but the blood-supply is 
regulated according to the needs of the tissue by the vasomotor nerves. 
When action of these nerves is destroyed the part is simply placed in an 
abnormal condition as regards its nutrition, and injuries are more easily 
produced and less easily repaired. 

A peculiar variety of inflammation is that known as sympathetic 
inflammation. Certain organs of the body stand in a particularly close 
relation with one another, and inflammation of one is followed by inflam- 
mation of the other. The best example of this is given in the infectious 
parotiditis, or mumps. In this the acute inflammation of the parotid 
gland is frequently followed in the male by inflammation of the testicles, 



VLCEBATION. 187 

which often reaches a severe degree, and in the female by a similar 
inflammation of the mammary glands and ovaries. The cause of this is 
absolutely unknown. It may be that the infectious agent, whatever its 
nature, which causes the inflammation of the parotid is localized in the 
other organs, or it may be that the chemical products which are produced 
in the inflammation of the parotid gland have a special pathogenic influence 
on other parts of the body. The fact that the inflammation of the other 
parts does not usually take place simultaneously with that of the parotid, 
but at a later stage of the disease, would seem to be in favor of the latter 
theory. There is certainly no direct nervous or vascular connection between 
the glands. It is only the specific infectious parotiditis which is followed 
by these sympathetic inflammations. Abscesses of the parotid due to the 
entry of bacteria into the gland along the duct are not followed by sym- 
pathetic inflammations. Another example of the sympathetic inflamma- 
tion is the inflammation of one eye which follows inflammation of the 
other. It is only when inflammation affects certain parts of the eye that 
the other eye is apt to become aff'ected. Inflammation of the conjunctiva 
or of the cornea is not followed by any affection of the other eye. It is 
only when the inflammation affects the iris and the deeper parts of the 
eye supplied by the sympathetic nerves that inflammation of the other eye 
takes place. Deutschman, who has investigated the subject by inoculating 
one eye with various bacteria, has thought that he could follow the course 
of the inflammation along the optic nerve to the chiasm, and then to the 
other eye. He supposes that it is due to bacteria which take this route. 
His experiments have been carefully repeated by Eandolph at the Johns 
Hopkins Hospital with negative results. Against the view of Deutsch- 
man that the affection of the uninjured eye is due to bacteria is the fact 
that the specific infections of one eye are not followed by similar affections 
of the other. Thus tuberculosis of the iris and of the other parts of the 
eye may destroy one eye without producing any lesions whatever in the 
other. As a rule, it is only acute suppurative inflammations which tend 
to extend in this way. It is possible that the inflammation may be due 
to the action of specific chemical substances produced in the inflamed eye 
on the other. The whole question of sympathetic inflammation, how- 
ever, is still very obscure. 

Ulceration. 

An ulcer is a loss of substance on a surface of the body. Ulceration 
is very closely connected with inflammation, and is frequently due to 
this. The ulcer really I'epresents a part of an abscess-wall. If an 
abscess is seated in the subcutaneous tissue and opens on the skin, there 
may be continuous inflammation and suppuration along the canal which 
leads to the abscess-cavity, and in this way fistulse are formed. The wall 
of the fistula leading to the old abscess has the same membrane which is 
found in the abscess itself. When the abscess is superficial, and when 
the opening is almost as large as the abscess itself, we do not speak of 
it as a fistula, but the opening together with the abscess is spoken of as 
an ulcer. In the ulcer there is always a loss of substance, exposing the 
deeper parts of the tissue unprotected by epidermis, and a chronic 
inflammation of these deeper parts. The ulcer ordinarily arises in 



188 



SUBOICAL PATHOLOOT. 



consequence of inflammation or injury which destroys the Protec- 
tive surface and lays bare the tissues beneath. The base and edges 
of the ulcer have the properties of inflammatory tissue, and m their 
structure are similar to tissue which lines the wall of an abscess. The 
base of an ulcer, as a rule, is covered with a soft reddish tissue with 
an uneven surface. Often the surface is covered with small eleva- 
tions varying in size, which give it a granular appearance, and the 
small elevations are called granulations. The tissue of which the 
base of the ulcer is composed has received in consequence the name 
of granulation tissue, and the name has been extended to all similar 
tissues even when there are no granulations present (Fig. 7). The gran- 



FiG. 7. 




Dense cicatricial tissue at the bottom of an old ulcer of the leg. The blood-vessels are numer- 
ous, but are compressed by the surrounding tissue. 



ulations are simply the small elevations. The same sort of tissue is 
found in all sorts of chronic inflammations, and the name has been 
extended to characterize a group of tumors closely related to inflam- 
mation which have received the name of granulomata, because their 
tissue is similar to the tissue found in the granulations of an ulcer. 
These granulations appear to be composed of projecting masses of 
blood-vessels with newly-formed tissue around them. Sometimes the 
granulations are exceedingly well marked, in other cases not. They 
are in general best seen in ulcers of the skin. They are not pres- 
ent, to any extent at least, in ulcers formed in the alimentary canal, 



ULCERATION. 189 

and a deep-seated abscess-cavity does not contain them. Hamilton 
has advanced a rather ingenious explanation for the formation of 
these granulations : It is known that all liquids and tissues of the 
body are under a certain pressure, and the force exerted in the dis- 
tention of the blood-vessels by the heart is opposed by the elasticity of 
the tissue around the vessels, which prevents any marked degree of 
dilatation. All the so-called cavities of the body, such as the peri- 
toneum, pleura, and pericardium, have their surfaces in accurate ap- 
position or are filled with some resisting material which counter- 
balances the pressure of the blood. If an inflammatory exudation 
takes place between the surfaces of the pericardium, the pleura, or the 
peritoneum, the transudation of fluid into the cavity goes on until 
the pressure in the cavity becomes equal to that of the blood-vessels 
in the walls. Hamilton supposes that the granulations are formed by 
the dilatation of the blood-vessels and their extension upward toward 
the surface, where they are not opposed by the pressure of the tissue 
over them. In this way, by the longitudinal extension of the vessels, 
projecting loops would be formed. It is very probable that this lack of 
pressure of the surrounding parts has much to do with the dilatation 
of the blood-vessels which is found in a granulating surface and the 
slow movement of the blood in the vessels. The efifect of removal of 
pressure is almost the same as would be produced by placing the entire 
hand in a vessel from which the air is exhausted. All of the blood-ves- 
sels would become more or less dilated, and there would be an increased 
difficulty for the passage of blood from the part, while the flow of blood 
to the part would be greatly accelerated and the transudation of fluid 
greatly increased. It is not probable that Hamilton is right in consider- 
ing that the granulations on the surface of a cutaneous ulcer are due 
solely to the action of these influences on the normal blood-vessels, 
because there are no such groups of blood-vessels in the skin to which 
these granulations could conform. It is probable, however, that the 
absence of pressure has something to do with it. 

The ulcer represents the best type of a chronic inflammation. The 
tissue is deprived of its protecting epidermis, and is subject to a contin- 
uous injury which will persist until the covering of epidermis is again 
restored. The tissue is not only subjected to the constant action of irri- 
tating substances, but also to drying. On the surface of the ulcer there 
is always a more or less superficial layer of necrosis. In the necrotic 
tissue and immediately below it there will be a variable number of pus- 
cells. These come not only from the normal blood-vessels of the part, 
but the emigration also takes place in the same way from the blood-ves- 
sels of the granulation tissue. The granulation tissue covers the entire 
base of the ulcer and extends to a variable depth in the tissue beneath. 
In places this extension into the deeper tissues is much more marked 
than in others. The granulation tissue is composed of small round cells 
closely packed together, with very little intercellular substance. On 
shaking the cells from a thin section little or no fibrilla-connective tis- 
sue is found between the cells, but the cells are held together by a 
mucoid substance. Blood-vessels are extremely numerous in these 
granulations. They are dilated, the blood flows in them with com- 
parative sloAvness, and, in spite of the number of blood-vessels, it is 



190 SURGICAL PATHOLOGY. 

probable that less blood flows into the part, for the supply of the large 
vascular area of the granulation vessels is frequently only a small artery. 

Repair of Inflammation. 

When the cause of the inflammation is temporary the inflamed part 
returns very quickly to a normal condition. The vessels return to their 
normal calibre, the leucocytes cease to accumulate in the periphery and to 
emigrate, and the stagnation of the blood in the dilated vessels passes 
away. This may take place before any exudation has been formed. 
When exudation has taken place, this may not disappear, and the 
inflamed part cannot return to its normal condition because the presence 
of the exudation itself produces more or less injury to the tissue, affect- 
ing its nutrition in various ways and acting as a cause of inflammation. 
There is no difficulty in the removal of the fluid portion of the exuda- 
tion. It is simply taken up and absorbed by the lymphatics of the 
part — a certain amount of it also by the veins. Even while the exuda- 
tion is taking place there is increased absorption of the fluid, and an 
inflammatory cedema or a serous exudation soon disappears when the cause 
producing it has disappeared, and no new exudation takes place. Even 
the corpuscular elements of the exudation, and the fibrin as long as it is 
present in only slight amounts, may disappear. The colorless corpuscles 
can be removed in the same way as the fluids. They can enter directly 
into the lymphatics. The few red corpuscles in the exudation gradually 
lose their coloring material and are dissolved, and even the fibrin itself 
becomes changed into a granular emulsion which is taken up by the 
lymphatics. These simple processes of restoration are much more difii- 
cult when the mass of the exudation is very considerable, as in a large 
pleuritic exudation, an extensive pneumonia, or an extensive purulent 
inflammation. A large exudation may even oppose mechanical difii- 
culties in the way of restoration of the integrity of the tissues. The 
absorption of these large exudations makes great demands on the func- 
tions of the lymphatics, especially in individuals in whom the force of 
the blood- and lymph-circulation has been weakened by inflammation. 
In any case the restoration must take place very slowly, and it is better 
to shorten the process of absorption whenever it is possible by artificial 
removal of the exudation. The blood-vessels may be compressed by 
the exudation, and the active circulation of blood in them necessary 
for absorption may be prevented. When an exudation is solid, being 
composed principally of leucocytes and fibrin, it must become in a 
measure liquefied before absorption can take place. In acute croupous 
pneumonia the exudation in the air-cells in consequence of fatty degen- 
eration becomes converted into an emulsion, which can then be absorbed 
by the lymphatics and blood-vessels of the lung or can pass into the 
bronchi and be so removed. It is evident that the richer the exudation 
is in solid elements, the slower it ^\\\\ be absorbed, and this holds espe- 
cially for exudations composed of pus-cells. In this the reason for 
artificial removal is still more forcible, because not only is the absorption 
of such an exudation more difficult, but as long as the exudation con- 
tinues, containing as it does the bacteria which produce it, it acts as a 
further cause for inflammation. 



REPAIR AND REGENERATION. 



191 



When not removed the exudation may become changed into a yellow- 
ish-white, more or less dry mass of about the consistency of cheese. This 
is spoken of as the caseation of the exudation. It takes place preferably 
in those exudations due to definite causes, as in tuberculosis and syphilis, 
but it is not exclusively confined to these. Lime-salts may be deposited 
in this dry necrotic tissue, and it can be converted into a solid or gritty 
calcareous mass which must always remain in the tissue. It acts here 
as a foreign body, and, as other foreign bodies, it will continue to excite 
inflammation around it. 

When the exudation disappears by simple absorption by the blood- 
vessels of the part, it is spoken of as resolution. In many cases the 
normal circulation of a part will not be sufficient to effect the removal 
of the exudation, and new tissue and new blood-vessels must be formed 
before the exudation can be removed. This is spoken of as the organiza- 
tion of the exudation : it is seen best on serous surfaces. When there 



Fig. 8. 




Formation of connective tissue in blood-clot. (The specimen was obtained from Dr Halstead ) 
The clot first becomes infiltrated with leucocytes, and formation of tissue takes place proceed- 
ing from the deeper tissue : a, young connective-tissue corpuscles ; 6, leucocytes ; c. newlv- 
formed blood-vessel. 

is on the surface of the pleura a fibrinous exudation which reaches any 
considerable extent, it becomes organized. Beneath the exudation there 
is a regenerative new formation of tissue which takes place from the 
normal tissues. In this a tissue similar to the granulation tissue at the 
base of the ulcer is formed. New blood-vessels are developed in this 



192 SURGICAL PATHOLOGY. 

which project upward into the fibrin. The formation of granulation 
tissue continues along these blood-vessels, and finally a young connective 
tissue is formed, the exudation disappearing as this takes its place (Fig. 8). 
In cases of inflammation of serous surfaces the same cause which pro- 
duces the inflammation on one surface will act in producing an inflam- 
mation on the surface which it touches. When organization takes place 
a direct union by means of young connective tissue is formed between 
the two surfaces, and produces adhesions which may give more or less 
trouble in after life. The adhesions which are so frequently found 
between the visceral and parietal pleural surfaces are due to a preceding 
inflammation, which may have been of such a slight character as to have 
given rise to no symptoms and not to have been recognized during life. 
The exudation may in every place undergo organization ; even in acute 
croupous pneumonia the exudation within the air-cells of the lung may 
in certain cases undergo organization in the same manner as the exuda- 
tion on a serous surface, and there will always remain in the alveoli of 
the lung the newly-formed connective tissue. In inflammation which 
takes place in the parenchyma of organs the exudation may be in part 
removed in the same way, and a new tissue be formed which will not 
completely disappear. A certain amount of this new formation of 
tissue takes place in nearly all inflammations, and its presence may 
serve to indicate a preceding inflammation even when the exudation has 
disappeared. 

In the repair of inflammation, in the restoration of the tissues to 
their normal integrity, not only must the exudation be removed, but 
the injury of the tissue which has been the cause of the inflammation 
in the first place must be repaired. In any inflammation there is always 
a destruction of tissue, and the tissue destroyed must be replaced by 
a new formation of tissue. This begins early, and may be seen while 
the inflammation is advancing. The new formation of tissue may be 
better studied in slight injuries of the cornea than elsewhere, and here 
the two processes, the vascular phenomena with the formation of the 
exudation and the new production of tissue, can be considered separately. 
When the loss of tissue is very slight, and when the action of the injury 
which caused it subsides at once, inflammatory phenomena with exuda- 
tion and emigration do not necessarily take place. In the ordinary 
physiological processes of life, and in all tissues, there is constantly 
taking place a loss of material which is supplied without any inflam- 
matory phenomena. The power of the tissue to supply a loss is greater 
than is ordinarily called for, just as in the circulation there is a reserved 
force in the power of the heart which can meet all ordinary conditions 
called for, and even extraordinary conditions, by an increased muscular 
action. In all the tissues of the body there is a greater power of repair 
than is ordinarily called for. But in the tissues, as in the circulation, 
this reserve force has its limit. The destruction of any considerable 
amount of tissue is always followed by inflammation. Even when the 
cause which produces the injury subsides at once, still the injured tissue 
itself will act as a sufficient cause. AVhen a cornea is touched with the 
end of a thread saturated with sulphate of zinc, a very limited injury 
will be produced. This is followed by a new formation of cells in the 
territory immediately around the injury, to take the place of the cells 



REPAIR AND REGENERATION. 193 

which have been destroyed. This new formation of cells begins forty- 
eight hours after the injury, and the same phenomena of cell-division 
take place that we find in cell-division anywhere. The nuclei of the 
cells divide by karyokinesis. Long processes are formed which extend 
up into the necrotic tissue, and the nuclei from the old cells travel up 
into these. In many cases there seems to be a difference in the regen- 
eration of tissue, depending upon the degree of destruction. In the 
minor degrees of injury, where only the cells themselves are destroyed, 
there is simply a new formation of cells having the same character 
as the old, without any intermediate stages. In one point the patho- 
logical regeneration of tissue differs materially from the physiological. 
It is frequently not confined to a simple restoration of the tissue lost, 
but the amount produced widely exceeds this. In inflammation of the 
skin there is often an excessive epithelial growth, and scars may be 
produced from the connective-tissue regeneration which at first pro- 
ject beyond the level of the skin and appear as red elevations. In the 
inflammatory regeneration of bone more callus is produced than is neces- 
sary for tlie supply of the portions of bone which have been lost. The 
power of regeneration is different not only in the diflferent tissues of 
the body, but also in different animals. The higlier the organization and 
the greater the differentiation of tissue, the less is the power of regen- 
eration, which is greater the younger the animal and the nearer it comes 
to an embryonic condition. In some of the lower animals, as the Crus- 
tacea, an entire part may be removed, and it may be completely re-formed. 
In the frog the power of regeneration is much more marlced in the tad- 
pole than in the adult. When the tail of the tadpole is removed an 
entire new production of tissue will take place. The different tissues 
also show dififerent powers of regeneration after loss. Tlie more com- 
pletely differentiated the tissue and the farther it is removed from an em- 
bryonic condition, the less is the power of regeneration. In some tissues 
it is probable that there is no new formation of cells, and only the 
portions of the cells which have been used up by the physiological pro- 
cesses will be restored. After injur}' in the central nervous system there 
is no new formation of nerve-cells. The same thing is true to a more 
limited extent in the striated muscles. Any loss in these tissues is sup- 
plied by a growth of connective-tissue elements. In certain of the 
glandular organs the power of regeneration is greatly limited. 

The new formation of connective tissue in inflammation does not 
always take the form of a pure regeneration. In the place of the nor- 
mal connective tissue a somewhat different tissue is formed, which is 
designated as cicatricial tissue. This cicatricial tissue differs from the 
normal connective tissue in the paucity of its cells and blood-vessels 
and in the density of its intercellular substance (Fig. 7). The charac- 
ter of the intercellular substance seems to be similar in general to white 
fibrous tissue, but its exact character has never been fully made out. 
The fibrillae are more firmly interwoven together, and cannot be sepa- 
rated so easily as they can in white fibrous tissue. In some inflammations, 
especially in the more chronic, the new formation of connective tissue 
may so greatly exceed the necessary amount to supply the defect, and 
form so prominent a part of the inflammatory process, that inflamma- 
tions of this character have received a different name and are known as 

Vol. I.— 13 



194 SURGICAL PATHOLOGY. 

productive inflammations. The excessive amount of connective tissue 
which is formed may often exert a deleterious influence on the future 
life and the functions of the inflamed part. 

In order that any new formation of tissue may take place new blood- 
vessels are necessary. The old blood-vessels of the part where the new 
tissue is to be formed have been destroyed to a great extent, and multi- 
plication of cells will not take place except under the best conditions of 
nutrition. If regeneration to any extent takes place in non-vascular 
parts, these become vascular. In any extensive injury of the cornea 
new blood-vessels grow into the tissue from the sclera in a comparatively 
short time. In man ulceration of the cornea is always followed by a 
vascularization of the portion of the cornea between the ulcer and the 
sclera. These new blood-vessels are formed from the old. The for- 
mation takes place by direct outgrowth from the old vessels. In this 
formation both the endothelium of the vessels and the connective-tissue 
cells in the neighborhood of the vessels take part. The process is the 
same as in the new formation of blood-vessels in the embryo. It can 
be well studied in the regeneration of tissue which takes place after cut- 
ting off the end of a tadpole's tail. The first thing which seems to take 
place is an enlargement of the endothelial cells of the vessels. These 
become large, filled with protoplasm, and long projections extend into 
the neighboring tissue. The nucleus of the cells divides, and nuclei 
pass up into the projection in very much the same way as in the regen- 
eration of the cells of the cornea. The connective-tissue cells in the 
vicinity enlarge, and arrange themselves either alongside of the projec- 
tion from the endothelium or as a continuation of this. In this way 
pointed processes of some length are formed. These meet with similar 
processes from the same vessel or from neighboring vessels, and in this 
way loops are formed which are at first solid. These solid processes are 
gradually hollowed out and become continuous with the lumen of the 
vessel. In some cases the lumen of the vessel gradually follows the 
formation of the sprout. In other cases loops are formed before the 
communication with the lumen of the vessel takes place. In this new 
formation of blood-vessels there must be a process somewhat similar to 
chemotaxis. In the cornea the blood-vessels are always formed from 
that portion of the sclera which is nearest the ulcer, and they show no 
tendency at all to extend anywhere but into the cornea. In the forma- 
tion of the loops there must be also a mutual attraction for the cells, 
because the meeting of the pointed process from the same or from 
neighboring vessels, and the resulting formation of loops, cannot be 
regarded as a matter of chance. This new formation of vessels always 
proceeds from the capillaries, and the newly-formed vessels are always 
of this character. They function as the old vessels. When the inflam- 
mation continues emigration takes place from them as readily as, or 
more readily than, from the old vessels. They are more easily dilated, 
and when dilated the dilatation frequently persists for some time. Later, 
these vessels may become diflferentiated into both arteries and veins, but 
the manner in which this differentiation is produced has not been fully 
made out. Other modes of new formation of the vessels have been 
described. According to some authors, the cells in the inflamed part, 
the cells of the tissue, may collect together in rows and may become 



REPAIR AND BEOENEBATION. 



195 



changed into endothelial cells, and a communication be established be- 
tween the old vessel and the newly-formed ; or large cells of the tissue 
may become hollowed out and in this way new cells are formed. 



Fig. 9. 




Section through a portion of a suture which had remained in the tissue eleven months. The 
suture first becomes infiltrated with leucocytes , and the formation of connective tissue takes 
place as in Fig. 8. The section represents only a fragment of the suture : a, o, silk flbrillse 
surrounded by dense connective tissue; 6, 6, giant-cells enclosing flbrillse. 

Strieker believes that not only are new vessels formed from the cells in 
this way, but that there may be a new formation of red corpuscles in 
these vascular cells in the same way as in the embryo. The essential 
cause of the new formation of blood-vessels and the influence which 
leads to it are obscure. We know only, in general, that they are formed 
in accordance with the law of nutrition — that where more blood is 
required for a part it will be given, either by a dilatation of the old 
vessels or, if this be not sufficient, by a new formation of vessels. 

There has been considerable controversy with regard to the participa- 
tion of the leucocytes in the new formation of tissue. Cohnheim be- 
lieved that not only were all the cells found in an inflamed part leuco- 
cytes, but that any new formation of tissue takes place from leucocytes. 
He was led to this belief by a number of experiments. He showed 
that there could be a new formation of tissue in parts in which all the 
living cells were destroyed by boiling and which were afterward placed 
in the peritoneal cavity of animals. The tissues became filled with 



196 SURGICAL PATHOLOGY. 

leucocytes which wandered into them, and, as a newly-formed connec- 
tive tissue with blood-vessels was afterward found in the tissue, he 
believed that this new formation must take place from leucocytes. Some 
experiments which Ziegler made on this subject seemed to be at first con- 
clusive. He enclosed two thin plates of glass with a capillary space be- 
tween them in the subcutaneous tissue or in the peritoneum of an animal, 
and found that a thin lamella of connective tissue was formed between 
the plates (Fig. 9). The first thing seen in such conditions is a filling 
up of the spaces between the plates with leucocytes and fibrin. After- 
ward large cells with a round nucleus and a large amount of protoplasm 
appeared, and from these large cells the formation of connective tissue 
takes place, either by a differentiation of the body of the cell into fibrous 
tissue or by a sort of secretion from the cell. The exact method in 
which this formation takes place has not been fully made out. Ziegler 
supposed that these large cells were produced directly from the leuco- 
cytes, but a repetition of his work by other observers has shown that 
they, like the leucocytes, wandered into the glass cell from without. In 
any case the new formation of tissue seems to take place from the 
large protoplasmic epithelioid cells (Fig. 8). The leucocytes probably 
take a part in the process, but only a passive one. Many of these 
large cells are phagocytic in character, and it is probable that the leuco- 
cytes play a distinct part in furnishing them nutrition, being taken up 
and devoured by these large connective-tissue cells. 

Sometimes there is in this way new formation of cells from the old, 
which simply supplies the tissue which has been lost. In this new for- 
mation of cells all of the tissues can take part. It is probable that the 
cells most actively concerned in it are the cells of the small blood-ves- 
sels. In other cases there is not an immediate formation of cells from the 
cells of the old tissue, but there are intermediate steps. The new tissue 
is not formed directly from the old, but there is a formation of granula- 
tion tissue first. In the cornea, for instance, if the loss of substance is 
extremely small, it may be supplied by a simple new formation of cells ; 
if larger, there will be a preceding formation of granulation tissue. 
Some of the granulation cells will afterward differentiate themselves 
into tissue-forming cells. The tissue which is formed in this way from 
the granulation tissue is never so perfect as that formed directly. It 
always approaches the character of cicatricial tissue. The process of 
regeneration of tissue can also be studied on the ulcer, and in the 
ulcer we can also study the local conditions which may interfere 
with this regeneration. In the ulcer the regeneration of tissue must 
take place in two directions. There is not only a new formation 
of necessary tissue from the connective tissue, but a new formation 
of epithelium must also take place. Until the surface is covered 
over with epithelium it must be constantly subjected to various trau- 
matic influences which will keep up the inflammation. If the ulcer 
is small and the local conditions favorable, the epithelium will grow in 
from the edges, cover over the surface, and the inflammation will subside. 
This new formation of epithelium takes place solely from the surround- 
ing epithelium. It has been supposed by many that a new formation 
of epithelium may take place from the granulating surface of the ulcer. 
The proof of this was supposed to be shown in the fact that the growth 



INFLAMMATION. 197 

of epithelium does not always proceed evenly from the edges, but small 
islands of epithelium are sometimes formed in the middle of the ulcer, 
and from these a growth extends upward to the edges. These small 
islands which are formed in the centre of an ulcer do not represent a 
new formation of epithelium from the edges of the ulcer, but are the 
remains of epithelial tissues, such as sweat-glands or the sebaceous 
glands of the skin, which were not entirely destroyed by the injury 
which produced the ulcer. An ulcer never heals by a simple process 
of tissue-formation, such as is seen in the cornea, but there is always a 
formation of granulation tissue, and from this the regeneration proceeds, 
leading to the production of cicatricial tissue. The amount of cicatri- 
cial tissue varies with the extent and duration of the ulcer. It is 
exceedingly dense, firm, and contains few blood-vessels. It may extend 
into the surrounding tissues for a considerable distance beyond the actual 
seat of the ulcer. In the most common seat of ulceration, the anterior 
surface of the lower leg and ankle, there are numerous local conditions 
which interfere with the process of healing. In the first place, the 
ulceration is constantly repeated at the same spot. The tissue is not 
normal, it has not the normal vascular supply, and it reacts to injuries 
more easily. Not only is there this abnormal tissue with weak vascular- 
ization, but the ulcers usually arise in persons who have a local passive 
congestion. In the process of healing the new formation of blood-ves- 
sels does not so readily take place. As we have seen, in spite of the 
apparent vascularization of the tissue of the ulcer, it is really poorer in 
blood-vessels. Frequently, healing will not take place until the dense 
cicatricial tissue resulting from a series of old ulcers is removed in toto, 
or until incisions be made through it so as to allow vascularization to 
take place from the deeper and more healthy tissues beneath it. 

The Effect of Inflammation on the Body as a Whole. 

The objection was early made to the theory of inflammation of Cohnheim 
that all of the cells found in the inflamed part could not come from the 
blood, because there were not enough cells in the blood to j)roduce these. 
In an acute fibrinous pneumonia one entire lung and a portion of the other 
may be so filled up with the inflammatory exudation as to resemble a 
solid mass and to sink in water. The consolidation of the lung is due 
in large part to an accumulation of leucocytes, and in a case of advanced 
pneumonia the number of leucocytes in the lung could not be estimated 
by numbers, but by pounds. The same thing is true in the large puru- 
lent exudation which we find in empyema or in peritonitis. There 
are at no time enough leucocytes in the blood to form such masses 
even if all of them could be taken up. It was supposed also that 
after the leucocytes had emigrated from the vessels they multiplied, 
and that many of them could be newly formed from those which at 
first emigrated. In speaking of this Cohnheim says that in general 
we can form little idea of the number of leucocytes in the blood from 
microscopic observation, because large numbers of leucocytes break up 
and disappear the moment the blood is taken on the slide for examina- 
tion. He also suggests that there may be a new formation of leuco- 
cytes in the blood, and an increase in their number due to this. He 



198 SURGICAL PATHOLOGY. 

called attention to the enlargement of the lymphatic glands and spleen 
frequently seen in acute inflammation, and supposes that this may ia 
some way stand in relation to the number of leucocytes found in 
the exudation. Cohnheim, however, made no estimate of the supposed 
increased number of leucocytes in the blood. As early as 1842, Gul- 
liver called attention to the similarity between the pus-cells and the 
leucocytes, and thought that in inflammation the white corpuscles of the 
blood were increased; and he instances a case in which, in a stallion 
which had a large abscess, the white corpuscles of the blood were almost 
as numerous as the red. Virchow also, in his study of the blood in leu- 
caemia, recognized the fact that in most acute inflammations, especially 
if they were at all extensive, the white corpuscles of the blood increased 
in number. He supposes that this is due to the fact that the lymph- 
glands and other blood-forming organs undergo a stimulation which 
excites them to an increased activity. We know now that in any inflam- 
mation, and especially in an infectious inflammation characterized by 
extensive exudation and emigration, the white corpuscles are increased. 
It is only recently, when the study of the corpuscular elements of the 
blood has received great attention, that the extent and importance of this 
leucocytosis have been recognized. The leucocytosis keeps almost an exact 
pace with the fever and the extent of the exudation. In croupous pneu- 
monia we have the greatest extent of leucocytosis, and the number of 
leucocytes in the blood may be double or treble that of normal. The 
leucocytes Avhich are found in increased number are exclusively of the 
polynuclear variety. The fact that in inflammations uncomplicated with 
hyperplasia of the lymphatic glands there is no increase in the mono- 
nuclear leucocytes speaks against the emigration of these and their taking 
part in the exudation. The mononuclear leucocytes are increased in 
typhoid fever and in other processes connected with a lymphatic hyper- 
plasia. The recognition of a polynuclear leucocytosis in the blood is 
frequently of great importance in determining the character and extent 
of inflammation. We find other changes in the blood in addition to the 
leucocytosis, but they probably depend in large measure upon this. If 
the inflammation is sufficiently extensive and lasts long enough to inter- 
fere with the general nutrition of the body, a diminution in the number 
of red corpuscles may take place. In acute inflammations, especially 
when connected with an extensive leucocytosis, there is an increase in 
the fibrin of the blood. This has long been known, and was formerly 
used as a diagnostic means for recognizing the extent and character of 
an inflammation. Although the fibrin is increased in the blood in 
inflammation, it coagulates more slowly. This slow coagulation of the 
blood allows the red corpuscles to sink from the surface of the blood 
before coagulation takes place. As a result of this, on the surface of 
the clot there is a layer of coagulation which has a buffy or straw color. 
This is known as the bufiy coat of the blood, and in the old days of 
bloodletting a great deal of importance was attached to it. Fever is a 
frequent accompaniment of inflammation. 



FEVEB. 199 



n. FEVER. 



Fever can well be considered in connection with inflammation, for 
it is an almost constant accompaniment of it, and the effect on the general 
organism of a local inflammation is shown first of all in the production 
of fever. In fever the normal temperature of the body is increased. 
Usually this increased temperature is accompanied by other abnormal 
conditions, but these are not necessary to the condition. Observations 
on normal individuals show that the temperature of the body, in spite 
of variation in the surrounding temperature and in spite of all sorts of 
changes in the external conditions of life, has a medium value of 37.2° 
to 37.4° C. The absolute variations in the course of the day may be 
from 1° to 2.5° C. The body is able to maintain such a temperature, far 
above that of the surrounding medium, only by the production of heat 
by means of chemical processes taking place in the tissues. The produc- 
tion of heat is offset by a discharge of heat, which takes place by means 
of the skin, the lungs, and the various excreta of the body. Ordinarily, 
the production of heat and the discharge of heat are so evenly balanced 
that the temperature of the body remains the same in all conditions. 

The Production op Heat. 

The various chemical processes which take place in the body are 
accompanied by the production of heat. At every muscular contraction, 
in all the processes of glandular secretion, heat is produced. Of all the 
tissues of the body, the muscles, not only from their bulk, forming as 
they do a large part of the whole frame, but also from the character of 
their metabolism, must be regarded as the chief source of heat. Not only 
is heat produced in the contractions of the muscles, but during their 
quiescent period metabolic changes are taking place in them by which 
heat is produced. Next in importance to the muscles are the various 
secreting glands. The secreting elements of the glands in the periods of 
secretion, and probably in the quiescent period, are in a state of meta- 
bolic activity which must give rise to heat. In the case of the salivary 
gland the temperature of the saliva secreted during stimulation of the 
chorda tympani is 1° to 1.5° higher than that of the blood in the carotid 
artery. The blood in the hepatic vein is the warmest in the body. In 
the dog a temperature of 40.73° has been observed in the hepatic vein, 
while that of the vena cava was 38.35° and that of the right heart 37.7°. 
The brain, too, may be regarded as a source of heat, since its temperature 
is higher than that of the arterial blood with which it is supplied. The 
other tissues of the body also serve as sources of heat, but the part they 
play is insignificant as compared with the muscles and glands. 

The increase of temperature of the body in fever may be due to 
either of two conditions : There may be increased production of heat, 
the discharge being the same or even increased, or, the production being 
the same, the discharge of heat may be reduced. One of the best 
known of the theories of fever was that advocated by Traube. Accord- 
ing to his views, there was no increased production of heat, but the 
increased temperature was due to a decrease in the discharge of heat. 
The discharge of heat he supposed to be least in the earlier period of 



200 SUBGICAL PATHOLOGY. 

fever and increased in the defervescence. A great deal of work has been 
done to determine whether there is increase of heat in fever, and its 
degree. Various methods have been used to determine this. The heat 
being the result of chemical changes in the body, it was sought to deter- 
mine if these chemical changes were more active in fever. It is known 
that most fever patients lose weight and that there is increased consump- 
tion of tissue. The urea is increased, and for a long time it was believed 
that the increased excretion of urea afforded satisfactory evidence of 
increased oxidation and increased production of heat. Of late years 
investigations have been made upon the consumption of oxygen and the 
production of carbonic acid in fever, and it is found that there is an 
increase in the amount of oxygen consumed and in the carbonic acid 
given off. In the beginning of fever, when the temperature is con- 
stantly rising, both of these processes are most active ; during the stage 
of defervescence the consumption of oxygen may fall below the normal. 
It has been claimed that the increased oxidation was not the cause of the 
fever, but simply resulted from the increased temperature of the body. 
Although it is true that there is an increase of oxidation in increased 
temperature, the elevation of the temperature 1° C. would only increase 
the oxidation 3.3 per cent., while in fever the oxidation may be increased 
13-16 per cent. Although it has been generally accepted that in fever 
there is increased oxidation of tissues and increased production of heat, 
this alone would not be sufficient to explain the high temperature. The 
increase in heat-production in fever is far less than would take place in 
an individual making active muscular movements in a cold environment. 
In health the increased heal^production is met by a corresponding dis- 
charge of heat, so that it has no effect on the body temperature. The 
loss of heat in fever has been investigated by direct calorimetry. The 
discharge of heat is least during the initial stage of fever, and increases 
during the stage of defervescence. During the hot stage the discharge 
of heat exceeds the normal, but usually, on account of the dryness of 
the skin, is not so great as might be inferred from placing the hand on 
the surface. In the febrile chill not only is the discharge of heat by the 
contraction of the vessels of the skin reduced to a minimum, but heat- 
production is excited to the utmost. As the result of the work of most 
investigators it may be said that in fever both heat>-production and heat- 
discharge are increased. 

Recently, Rosenthal, who has investigated this question by means of 
a specially constructed air-calorimeter, using animals in whom fever was 
produced by the injection of , various substances into the circulation, has 
returned to the view of Traube. He finds that in the initial stage of 
fever and in the stage of gradual increase of temperature the discharge 
of heat is diminished and there is no increased production of heat. 
When the fever has lasted a considerable time there is a return to the 
normal discharge of heat. The diminution in the discharge of heat he 
thinks is due to sudden changes in the circulation of the skin brought 
about by vasomotor influences. In the stage of defervescence the dis- 
charge of heat is greatly increased, and about corresponds to the decrease 
in the temperature. 

If the regulatory mechanism were normal, the discharge of heat in 
fever would be increased in proportion to the increased production and the 



FEVER. 201 

temperature would be unaltered. The regulating mechanism, although 
profoundly disturbed, is not paralyzed in fever. External cold in fever 
to some extent stimulates the heat-production, but not nearly to the same 
extent as in health. A person in fever is not able to maintain his tem- 
perature under the influence of heat and cold to the same extent as a 
person in health. It is not merely, as some have supposed, that the 
regulatory mechanism is set for a higher degree of heat, but that it is 
disturbed. In both health and fever the regulatory mechanism is under 
the control of nervous influence. This acts through the vasomotor 
nerves presiding over the superficial parts of the body, and by producing 
variations in the calibre of the cutaneous vessels controls in great meas- 
ure the discharge of heat. The perspiration which plays so great a part 
in the discharge of heat by evaporation is also under the influence of the 
nervous system. Heat-regulation is effected not only by means of varia- 
tions in heat-discharge, but heat-production is also under the influence 
of the nervous system. In a cold atmosphere more heat is produced, 
and in a warm less heat, provided the external temperature is not so 
high or so low as to make it impossible to preserve the body tempera- 
ture. To regulate the temperature simply by the discharge of heat 
would be like regulating the temperature of a room by opening the 
doors and windows and paying no attention to the furnace. There is 
every reason to believe that nervous impulses control chemical changes 
which result in the production of heat independently of visible altera- 
tions of the tissues, so that heat-production is in considerable part under 
the control of the nervous system. The nerves controlling the produc- 
tion of heat are known as thermic nerves, and they are controlled by cen- 
tres in the brain. The chief of these centres is in the nucleus caudatus, 
and if this centre is stimulated by puncture with a needle or by electri- 
cal stimulation, fever, often reaching several degrees above the normal, 
will result. A number of cases have been collected in which fever re- 
sulted in man from injuries involving these centres in the brain. It is 
very probable that fever may be the result of the stimulation of these 
centres in the brain by pyrogenic substances in the blood. Opposed to 
this is the htemic theory, which assumes that the increased temperature 
is due to the direct action on the tissues of pyrogenic substances con- 
tained in the blood. After puncture or stimulation of the caudate 
nucleus of animals they present all the phenomena of fever. There is 
increased heat-production, with increased consumption of oxygen, and 
the heat-regulation is also interfered with. 

Liebermeister regarded all the phenomena of fever, the changes in the 
pulse, respiration, etc., as due simply to the effect of the increased tem- 
perature. He urged that the weakness of the heart, which is undoubt- 
edly one of the most serious dangers in fever, was due to the increased 
temperature, which caused parenchymatous and fatty degeneration of the 
cardiac muscle. According to his views, the one great indication in 
treatment was to lower the temperature of the body. Of late there 
has been a reaction against these views of Liebermeister, which reaction 
has in part been brought about by the fact that antipyretic drugs may 
reduce the temperature, but may not affect the other phenomena of 
fever. Some authors have gone to the extent of not only denying that 
there is danger in temperatures which do not exceed a very high point, 



202 SURGICAL PATHOLOGY. 

but of stating that the elevation of temperature in itself may be a benef- 
icent provision of nature in warding off the effects of disease. It is 
obvious that the effects of high temperature cannot be studied in the 
fevers of man nor in the artificial fevers produced by the injection of 
various substances into the blood. The effects of the temperature must 
be separated from the effects produced on the tissues by the agents which 
cause the increase in temperature. The effects of temperature alone 
have been studied by subjecting animals to a high temperature. Some 
of the earlier experiments have seemed to bear out Liebermeister's view 
of fever. It was found that animals whose temperatures were artificially 
raised to 40.5° or 41.7° C. showed evidences of illness. All experi- 
menters agree that a mammalian animal dies when its temperature is 
raised to 44° or 45° C. Death is preceded by convulsions, and rigor 
mortis develops almost immediately after death. Death in these cases 
has been attributed to heart-paralysis due to heat-rigor, but it is known 
that heat-rigor does not take place at such temperatures. In all of the 
cases in which death took place after keeping the animal for some time 
at a temperature of 40.5°-41° fatty degeneration of the heart was found. 
The most complete set of experiments on the influence of high tem- 
perature alone was made by Welch at the Johns Hopkins Hospital. In 
all the previous experiments the animals were kept in small, dark, badly- 
ventilated boxes, and the influence of the high temperature was assisted 
by the bad surroundings of the animals. In Welch's experiments the 
animals were kept in a large box partially closed at the top by a blanket. 
The box was surrounded, except at the top, by a layer of water. The 
animals were supplied with an abundance of green food and water, 
which they took greedily. He succeeded in keeping two large black 
rabbits for two weeks with an average rectal temperature in one of 
41.4° C. and in the other 41.8°. The animals lost weight while in the 
box in spite of their abundant food, but otherwise seemed perfectly 
well. He found considerable differences in different individuals in 
their capacity of withstanding high temperatures, and thinks, in gen- 
eral, that black rabbits are more resistant than white. In all cases, 
after keeping the animals for some time, extensive fatty degeneration 
of the heart, liver, and kidneys was found. He is not inclined to 
attach so much clinical importance to the fatty degeneration of the 
heart as some have done. In a series of experiments which he made on 
animals in whom fatty degeneration of the heart had been produced by 
heat he found that the blood-pressure was kept at the usual height, and 
the heart reacted to nervous stimulation in the usual way. In one case 
he observed the contraction under the microscope of some fibres of 
heart-muscle in which the fatty degeneration was so advanced that no 
striation could be seen. He thinks from this that the effect of fever on 
blood-pressure is not due to increased temperature alone, but to other 
factors. Animals which had been rendered ansemic by bleeding were 
more affected by increased temperature than normal animals. Animals 
with an artificially increased temperature had their capacity for temper- 
ature regulation disturbed, so that they were more susceptible to the 
effects of heat and cold than normal animals. The various fevers differ 
materially in the effects produced. In relapsing fever temperatures can 
be withstood which in typhoid fever or pneumonia would be fatal. 



FEVER. 203 

In fever the frequency of respiration is increased. This has been 
attributed to the direct effect of the heated blood upon the respiratory 
centres in the medulla. The experiments of Goldstein made in Fick's 
laboratory are generally quoted as completely settling this point. He 
surrounded the carotid arteries with tubes in which hot water circulated, 
and found the respirations increased. In order to produce any appre- 
ciable increase of temperature in the blood rapidly flowing through the 
artery, by exposing the vessels for a space of a few cm. to warmer sur- 
roundings, the tube around the vessel would have to be very hot, and 
a high temperature in the surrounding tube would have so injured the 
vessel that coagulation would take place. Sihler repeated the experi- 
ments of Goldstein, and concluded that the increase in the respiration 
was not due to heating the blood, but to stimulation of the peripheral 
nerves. Welch found that in the hot box animals with a surrounding 
temperature of 32°-35° C. often preserve their normal temperature, 
though the respirations are increased. When animals with fever are 
taken out of the box the respiration often decreases before the temper- 
ature falls. The increased frequency of the heart's action is due to the 
direct action of the heated blood on the cardiac muscle. This has been 
shown by Martin on the isolated mammalian heart. When the heart 
is fed with blood of gradually increased temperature, the rapidity of 
the heart up to a certain degree keeps pace with the increased temper- 
ature. The heart continues to beat when supplied with blood of a 
much higher temperature than is found in fever. The nervous phe- 
nomena of fever cannot be attributed to the effect of high temperature 
on the nervous centres, for the effect of fever on the nervous centres 
may be entirely absent in relapsing fever and in the aseptic wound- 
fever. 

Fever may be due to an infinite number of causes. In general the 
fevers are divided into the symptomatic and the essential, though no sharp 
line can be drawn between the two. In the symptomatic fevers it is 
assumed that there are local lesions somewhere in the body from which 
substances are produced which when absorbed cause fever. At one time 
there was a theory that in an inflammatory focus there was a direct pro- 
duction of heat, and fever was the result of this local heat-formation. 
In a strict sense there are no essential fevers, and the distinction is a 
purely artificial one. Fever is generally due to the presence in the 
blood of substances which are capable of causing it, and to which the 
name pyrogenic has been given. A great deal of work has been done 
of late in the investigation of these substances. Most of the normal fer- 
ments of the body, particularly fibrin-ferment, may give rise to fever 
when injected into the blood. Of great interest in this connection is the 
aseptic fever which was described by Volkmann. It follows injuries to 
the tissue in which there is no possible infection. Nothing shows more 
clearly the line which should be drawn between the high temperature 
and the other phenomena of fever. This aseptic fever has no prognostic 
importance. In a case of subcutaneous fracture, with extravasation of 
blood into the tissues, temperatures of 40° C. or over may be seen without 
any other phenomena of fever save slightly increased pulse and respi- 
ration. 

Absorption of perfectly aseptic products of tissue-necrosis will give 



204 SURGICAL PATHOLOGY. 

rise to fever. Gangolphe and Commont have shown that the injection 
of the germ-free tissue-juice from gangrenous tissues is in a high degree 
pyrogenic. They also produced necrosis in the testicle by means of a 
ligature, and found that the fluid of the necrotic tissue produced fever. 
The power of fibrin-ferment in producing fever is well known. Any 
substance which will give rise to it acts as a pyrogenic agent. Thus 
water injected into the blood will give rise to fever. It has been claimed 
that most of the substances which produce fever act by producing coag- 
ulation in the capillaries and small blood-vessels, and so giving rise to 
fibrin-ferment. Hildenbrandt found that after the injection of various 
ferments into the blood there was extensive thrombosis of the small 
vessels in the liver, intestine, lungs, and kidney. The presence of fibrin- 
ferment cannot be regarded as the sole cause of the fever, for the highest 
temperatures are not found in the diseases in which the greatest quantity 
of ferment is found in the blood, and fever may be present in cases in 
which this ferment is entirely absent. 

It is questionable whether fever may be the result of irritation of 
the peripheral nerves. The cases usually cited as examples of this are 
the fever of children during teething and the fever which sometimes 
follows the introduction of a catheter. It does not seem reasonable that 
all cases of catheterization fever should be ascribed to the introduction 
of bacteria or to injury of the urethra. There are numbers of cases in 
which the careful introduction of an aseptic catheter has been followed 
by a chill and fever lasting a short time. The chill may follow so shortly 
after the introduction of the catheter that time is not given for the in- 
crease of bacteria should any have been brought with it, and it is not 
probable that the pyrogenic substances produced by bacteria elsewhere 
are on the catheter. Nor is time given for the development of sufficient 
inflammation to cause fever even if an injury was produced by the catheter. 
In many cases a temporary increased temperature is the only phenomenon. 
The case is difi^erent when fever follows the introduction of a catheter 
into an inflamed urethra or bladder. In regard to the question of pro- 
duction of fever from peripheral irritation, a strong argument against it 
is that it is only in certain parts of the body that such irritation is followed 
by fever. No irritation of the skin in general which is not followed by 
inflammation will produce fever. In the inflamed bladder or urethra the 
pyrogenic material is already present, and sufficient injury may be pro- 
duced to cause its absorption. Most of the chemical products of bacteria 
are pyrogenic. These may be absorbed into the circulation from a local 
lesion of some sort, or they may be absorbed from the alimentary canal 
without any local lesions being present. There is no doubt that abnormal 
processes of fermentation in the alimentary canal may produce chemical 
substances which when absorbed may give rise to increased temperature 
and the other phenomena of fever. 

It is easy to see why inflammation should be so constantly accom- 
panied by fever. In the inflammatory exudation, whether of an aseptic 
or septic character, substances are present which, when absorbed, are 
pyrogenic. Not only is there in every case fibrin-ferment, but the prod- 
ucts of simple necrosis of tissue are pyrogenic. If the inflammation be 
due to bacteria, there are added to the pyrogenic substances of the exu- 
dation the chemical substances produced by the bacteria. If there is no 



THROMBOSIS AND EMBOLISM. 205 

accumulation of the exudation in the tissues and no absorption, fever 
does not talie place. In wounds treated by the open method, where the 
products of the inflammation are not absorbed, there is no fever unless 
the inflammation extends into the surrounding tissues and allows 
absorption from these. The dependence of fever upon absorption is 
shown in its prompt decline when an inflammatory exudation, especially 
if it be purulent, is evacuated. There is good evidence that the increased 
temperature in fever is not in itself a source of danger unless it reaches 
a very high degree. There is also some evidence that the increase of 
temperature may not be an evil, but a beneficent agent. The most 
dangerous cases of pneumonia are frequently not those in which the tem- 
perature is highest. Serottin has found that when sterilized cultures of 
typhoid bacilli are injected into the blood of rabbits, recovery is more 
apt to take place when the temperature is elevated. Welch has observed 
the same thing. Cases of typhoid fever of especial malignity have been 
reported in which the temperature was subnormal throughout. It is no 
longer the custom to judge the severity of wound-fever by the degree of 
the temperature elevation. ISIany surgeons consider the condition of the 
circulation and other things of far more prognostic value than the evidences 
given by the thermometer. Dochman found that when cats were given 
curare the poisonous influence of the drug was far less when the animals 
were given a temperature of 40° C by keeping them in the warm chamber 
than when they were kept in ordinary temperatures. While there were 
apparently no symptoms produced in the heated animals, poisoning rapidly 
developed when they were exposed to ordinary temperatures. He further 
calls attention to the fact that all infectious diseases accompanied by fever 
have a tendency to recover, while the afebrile infectious diseases, such as 
leprosy and rabies, have no tendency to recover. 

From all we have seen of inflammation it seems evident that its 
phenomena are essentially conservative in their action on the organism, 
and it cannot be assumed that so marked a phenomena as the fever 
should have the opposite tendency.^ 



m. THROMBOSIS AND EMBOLISM. 
Thrombosis. 

Thrombosis is the coagulation of the blood in the vessels during life. 
When blood is taken from the vessels during life, after standing some 
time it undergoes coagulation, changing from a fluid to a solid form, 
and the vessel containing it can be inverted without spilling the contents. 

We owe the most of our knowledge of the process of coagulation 
and the factors concerned in it to the work of Alex. Schmidt and his 
pupils. Schmidt was able to separate from the blood two substances, 
each with definite chemical properties, to one of which he gave the 
name of paraglobulin and to the other the name of fibrinogen. The 
fibrin of the blood does not exist pre-formed in the blood, but is due to 

' In these remarks on fever extensive use has been made of the Cartwright Lectures 
on fever by Prof. W. H. Welch. 



206 SUBGICAL PATHOLOGY. 

the union of these two substances, the union being brought about by the 
presence of a third substance which has all the characters of a ferment, 
and which is called fibrin-ferment. This ferment is destroyed or ren- 
dered inoperative at the death-point of protoplasm and of the other fer- 
ment-substances of the body ; that is, at about 58° C. If the blood be 
heated to 58° C. before any coagulation has taken place, the power of 
undergoing coagulation is lost. The ferment appears to be principally 
contained in the white corpuscles and is set free by their disintegration. 
Other tissues of the body may contain this substance, or substances 
which are analogous to it and which act in the same way. A proteid 
substance may be obtained from the thymus gland which when injected 
into the circulation produces extensive coagulation in all the vessels and 
leads to the death of the animal. The disintegration of other tissues of 
the body also produces fibrin-ferment. In necrosis, substances are pro- 
duced which cause coagulation in the blood-serum which comes in 
contact with the necrotic tissue. 

A new theory of coagulation has been advanced by Arthur and 
Pages. These observers found that if a certain proportion of oxalate 
of potash be added to freshly-drawn blood, it loses its power of coagula- 
tion. They attribute the action of the oxalate to the precipitation from 
the blood of the soluble lime-salts which it contains. If a solution of 
chloride of lime be added to the blood containing the oxalate, coagula- 
tion will take place. 'No matter how long the oxalated blood may be 
kept, it will remain fluid, and coagulation will take place as soon as the 
lime-salts are driven from their connection with the oxalate and again 
set free in the fluid. The fibrin-ferment only acts on the fibrinogen, 
converting it into fibrin when lime is present. In coagulation the 
fibrinogen undergoes a chemical change by which it is converted into 
fibrin, the fibrin being a union of lime-salts and albumin. 

The coagulation of the blood in the vessels during life is prevented 
by some action exerted on the blood by the living endothelium of the 
blood-vessels. The blood contains the necessary element for coagula- 
tion, and a certain amount of fibrin-ferment must be constantly pro- 
duced by the disintegration of leucocytes and other cells, which to some 
extent is always going on. In inflammatory exudations and in the 
necrosis of the tissues fibrin-ferment is certainly present, and being 
soluble it must enter into the circulation. If a large vein of an animal 
be carefully ligated and removed from the body while filled with blood, 
coagulation of the blood contained in this receptacle does not take place 
for a long time, and when it does the clot is always thinner than when 
formed under ordinary circumstances. The serous tissues act in the 
same way in preventing coagulation. If small vessels are included 
between double ligatures, care being taken to prevent any injury to the 
vessel by the ligature, the blood in the vessels will not coagulate. Stag- 
nation of the blood in the absence of other factors will not produce 
coagulation in the vessels, but it will favor it. If the wall of the blood- 
vessel is injured in any way, thrombi M'ill be formed on the injured sur- 
face. It is not known to what this action of the living endothelium in 
preventing coagulation of the blood is due. It is not due to the smooth- 
ness of the surface alone, for Virchow has shown that thrombi will 
form around globules of q^uicksilver when they are brought into the 



THROMBOSIS AND EMBOLISM. 207 

circulation. It is probable that the prevention of coagulation is a 
property of the living endothelial cells. The endothelial cells do not 
simply provide a physical lining to the vessels, but have as definite prop- 
erties as gland-cells, and they may produce substances which oppose the 
action of the fibrin-ferment. 

Coagulation of the blood takes place in the vessels a few hours 
after death. Certain conditions favor or oppose the post-mortem coagu- 
lation. An excess of carbonic acid in the blood retards the coagula- 
tion, and in death after suffocation the blood is usually found fluid. 
The blood is fluid, or clots feebly, after death from certain poisons 
and from a number of infectious diseases, especially those due to the 
absorption of chemical bacterial poisons. The blood is firmly clotted 
after death from pneumonia, in which disease the fibrin-ferment in the 
blood is increased. The clot found in the vessels may resemble the clot 
formed outside of the body, or in certain places, notably in the heart, 
clots are formed which are colorless and transparent, and resemble the 
clot obtained by whipping the blood and gathering the fibrin. Clots of 
this sort are not strictly post-mortem. For their formation a certain 
amount of motion in the blood is necessary, and it is probable that they 
form in the last minutes of life, especially under circumstances in which 
the power of coagulation is increased, as in croupous pneumonia. 

Three principal varieties of thrombi may be distinguished, and there 
are various intermediate stages. The white thrombus is of firm con- 
sistency and has a grayish, and sometimes a yellowish-white, appearance. 
On microscopic examination it is principally composed of white corpus- 
cles and fibrin. Many of the white corpuscles are apparently normal 
and their nuclei stain clearly ; others show every stage of disintegration. 
The fibrin appears either in the form of very minute filaments, forming 
a meshwork and enclosing the leucocytes in its meshes, or the filaments 
may be large and coarse. At times the thrombus has a hyaline, more 
transparent appearance, and this is due to the presence in it of large 
masses of hyaline material which stain in the same way as fibrin, and which 
probably result from a hyaline metamorphosis of the fibrin. In many 
cases the fibrin is arranged in definite layers which may be stripped off. 
This is especially the case in the large thrombi formed in aneurisms. 
The whole space of the aneurism is frequently filled with lamellje of 
fibrin. Along with the leucocytes and fibrin a certain number of red 
corpuscles are generally found, and a quantity of granular material, 
which may result from disintegration of the fibrin or white corpuscles, 
or may have another origin. 

The red thrombus is less firm than the white. The red color is due 
to a greater number of red corpuscles, or pigment resulting from their 
disintegration, entangled in the meshes of the fibrin. The red thrombus 
shows various degrees of color, depending upon the amount of blood- 
pigment in it, and is formed more rapidly than the white. 

In the mixed thrombus there is a combination of both forms. It 
frequently has an exquisitely lamellated structure, a red lamella follow- 
ing a white in regular order. This mixture of the two colors is due to 
an alternation of rapid and slow coagulation on the surface. 

The consistency of the thrombus may differ in different parts. We 
can frequently distinguish a firmer portion of the thrombus to which 



208 SUJRGICAL PATHOLOGY. 

the remainder is loosely attached. The firm portion is the true throm- 
bus, which is due to the local cause, and the other is simply a coagulum 
formed on this. The soft red coagulum may extend from the thrombus 
a considerable distance in the blood-current, and is called the secondary 
or continued thrombus. When a vessel is completely occluded the 
thrombus extends up to the next branch entering or given* off from 
the thrombosed vessel. 

True thrombi may be distinguished from post-mortem coagula in 
a number of ways. Thrombi are more consistent than post-mortem 
clots ; they are more adherent to the walls of the vessels. The adhesion 
is due to several causes. If the thrombus be sufficiently old and if 
organization has taken place in it, there is a definite tissue-union between 
the thrombus and the vessel-wall. Even if there is not formation of 
tissue extending from the wall of the vessel into the thrombus, there is 
frequently a formation of fibrin in the wall of the vessel which unites 
with the fibrin of the thrombus. 

The thrombus may occupy various relations to the lumen of the 
vessel. It may fill up the entire vessel or occupy only a small portion 
of the wall, allowing the blood-current to flow past it. As a rule, 
thrombi are formed by coagulation over a small area of the wall of the 
vessel, and then successive coagula are formed on the first. In the heart 
these successive coagula may be formed until a large mass projecting 
like a polypus into one of the cavities of the heart is produced. 

Another variety of thrombus is due to aggregations of the blood- 
plates. There is still much contention about these blood-plates and the 
part which they play in coagulation and thrombus-formation. It is 
held, on the one hand, that they are essential constituents of the blood, 
and on the other that they result from the disintegration of white cor- 
puscles. Eberth and Schimmelbusch, in studying the experimental 
formation of thrombi, found that the first appearance of the white 
thrombus was due to a collection of these blood-plates. They form 
with the greatest rapidity just at the point where the vessel is injured. 
They call the thrombus so formed the blood-plate thrombus. Welch 
has also found that thrombi which at first are entirely composed of 
blood-plates can be produced experimentally by slight injuries of the 
wall of a blood-vessel, and it hardly seems probable that all the leuco- 
cytes which had collected at such a place could have broken down. 
Weigert does not consider these aggregations of blood-plates as true 
thrombi. He considers the thrombus a true coagulation of the blood, 
and not an aggregation of some of its constituents. A considerable 
amount of granular material which is found in the thrombus may be 
composed of these blood-plates. Zahn studied the formation of thrombi 
in the veins of the mesentery of a curarized frog directly under the 
microscope. He found that when a crystal of salt was placed in con- 
tact with the vein the first change noticed was a collection of leucocytes 
at the point. Finally, the entire lumen of the vessel was occluded by 
the leucocytes. In the course of some hours the thrombus underwent 
important changes. The white corpuscles lost their form and regular 
contours, and became changed into a more or less finely granular mass, 
and then fibrin-filaments appeared. 

Both local and general conditions favor the formation of thrombi. 



THROMBOSIS AND EMBOLISM. 209 

The local conditions favoring their formation are stagnation of the blood 
and changes or injuries in the lining membranes of the vessels. Exper- 
imentally, it seems to be shown that when the blood is enclosed in a vessel 
between double ligatures coagulation will not take place if the vessels 
be ligated so carefully that all injury to the wall is prevented. Even 
if we suppose that a lesion of the endothelium is necessary for coagu- 
lation, such a lesion may be produced by stagnation of the blood. 
The endothelium of the blood-vessels is nourished by the blood, and 
not only the blood, but its constant renewal, is necessary, and a loss of 
function of the endothelium due to lack of nutrition would suffice to 
produce coagulation. As a rule, the smaller the blood-vessel in which 
stagnation takes place, the less likelihood is there of coagulation. The 
larger the area of blood relatively to its mass which comes in contact 
with the endothelium, the less readily will coagulation take place. In a 
small vessel degeneration of the endothelium would not be so likely to 
take place, because it could more readily be nourished by imbibition 
from the surrounding tissues. The thrombi produced by stagnation of 
the blood are formed first in the pockets behind the valves, where the 
stagnation is most complete. Thrombi may form around foreign bodies, 
but there is little opportunity given for this mode of formation in man. 

Virchow first called attention to the part which alterations in the walls 
of the blood-vessels play in the formation of thrombi, and regarded the 
coagulation as the result of altered molecular attraction between the wall of 
the vessel and the blood. Ulceration, inflammation, necrosis, and various 
other pathological conditions in the neighborhood of blood-vessels may 
so affect their walls as to lead to thrombosis. Frequently the coagula- 
tion which takes place under such circumstances is essentially a con- 
servative process, and the hemorrhage which would otherwise follow 
the extension of the ulceration into a large vessel is avoided. Dilata- 
tions of vessels favor the formation of thrombi. The thrombus forms the 
more easily the more sharply circumscribed and the more partial the 
dilatations are. In such conditions, of which the best type is given in 
aneurism, the thrombosis is further assisted by calcification and various 
degenerations of the lining wall of the aneurism. 

Various conditions of the system favor the formation of thrombi. 
They are frequently found in weak marantic individuals, particularly 
when they have had long-continued suppuration. In such individuals 
thrombi are frequently found in the pockets behind the valves of the 
veins, in the sinuses of the dura mater, and in the auricular appendages 
and between the muscular trabeculse of the heart. Virchow considered 
the essential factor in the production of such thrombi the weakness of 
the heart and circulation. Even in such conditions the thrombosis may 
be favored by local degenerations of the endothelium. The nutrition 
of the vessels will suffer in consequence of the diminution in the gen- 
eral nutritive power of the blood and the diminution in its rapidity of 
flow. These conditions will be felt most where local conditions favoring 
stagnation are present. 

There may be certain chemical alterations in the blood which increase 
its coagulability. The injection into the blood of the extracts of certain 
glands, especially of the thymus gland, increases its coagulability. 
Extracts of hsemoglobin, especially the hemoglobin derived from 

Vol. I.— U 



210 SURGICAL PATHOLOGY. 

a different animal, has the same effect. There were numerous ex- 
amples of this when the blood of different animals was used for trans- 
fusion. Under such circumstances death frequently occurred shortly 
after the transfusion, and at the autopsy extensive thrombosis was found. 
In certain cases there may be such extensive thrombosis in the vessels 
that the existence of substances in the blood which materially increase 
its power of coagulation must be assumed. These are cases in which 
in a very short time, and apparently without any lesions in the walls of 
the vessels, there is extensive formation of thrombi. It is possible that 
substances may be formed in certain organs of the body, and may have 
a local influence in assisting thrombosis. There ma}'^ be extensive 
thrombosis, especially in the very smallest veins and capillaries, which 
occurs in the course of certain infectious diseases. The thrombi formed 
under these circumstances are different from the ordinary thrombi, being 
composed almost entirely of hyaline material. Such thrombi are fre- 
quently found in vessels of the kidney and the lungs. 

The thrombus when once formed undergoes various changes. It 
contracts and becomes firmer and harder. Softening frequently takes 
place, especially in large thrombi formed in the heart and large vessels. 
The thrombus becomes converted into a soft pulpy mass of an opaque 
granular appearance closely resembling pus. The softening most fre- 
quently takes place in the centre of the thrombus. In the softened 
material of the thrombus there is a quantity of fatty granular material 
which is derived from the breaking down of both the cells and the 
fibrin. The fluid in the centre is frequently surrounded by a dense 
outside wall. The fluid results both from the absorption of fluid from 
the blood and the contraction of the thrombus. This softening may 
take place until the thrombus resembles a cyst filled with fluid. The 
thrombus may become organized and converted into a mass of connec- 
tive tissue. The manner in which the organization of the thrombus 
takes place has been the subject of a great deal of dispute among path- 
ologists, and the study of the process has led to a material increase of 
our knowledge about this and the formation of pathological connective 
tissue in general. It was at first supposed that the connective tissue in 
the thrombus was formed by a direct conversion of the constituents of 
the thrombus into connective tissue. It is now known that the organ- 
ization of the thrombus is due to a growth of connective tissue into 
it from the wall of the blood-vessel. It is not probable that the white 
corpuscles in the thrombus itself take any part at all in the organization. 
In the first stages of the organization of the thrombus it becomes filled 
with leucocytes which are derived from the wall of the blood-vessels. 
In some cases it seems probable that there may be an invasion of the 
thrombus by leucocytes which are derived from the blood itself. After 
the leucocytes, and along with them, large epithelioid cells appear which 
are derived from the walls of the vessels. These cells are accompa- 
nied by a new formation of blood-vessels proceeding from the adjacent 
blood-vessels of the tissue, and a new formation of connective tissue 
takes place from the large epithelioid cells. The leucocytes appear to 
prepare the way for the after-formation of tissue, and, as in the connec- 
tive-tissue formation in inflammation, it is probable that they to some 
extent furnish food for the growing cells. The thrombus in "the course 



THROMBOSIS AND EMBOLISM. 211 

of organization becomes filled with large dilated blood-vessels that fre- 
quently communicate with one another. Under favorable circumstances 
communications may be formed between the blood-vessels of the throm- 
bus and the lumen of the vessel, and in this way the continuity of the 
lumen of the vessel may be again accomplished. The red thrombus in 
the course of time becomes decolorized and converted into a yellowish 
or yellowish-brown material. The thrombus may become calcified, and, 
in consequence of this, becomes converted into a hard, calcareous mass. 
The so-called vein-stones, or phleboliths, are due to calcification of 
thrombi. The calcification is due to the deposition of lime-salts in the 
thrombus. All of these changes in the thrombus are relatively favor- 
able. Other changes are not so favorable. There may be an actual 
purulent softening of the thrombus. When there is purulent inflam- 
mation in the tissues around the thrombosed vessel the suppuration 
may extend to the blood-vessel and into the thrombus. Not only may 
the pus-cells wander from the vasa vasorum and enter the blood-vessel 
and thrombus, but the pyogenic bacteria may also be carried by these. 
Under such circumstances no organization of the thrombus takes place, 
and it becomes converted into a soft friable mass. 

Embolism. 

Although the thrombi may produce both local and general effects on 
the circulation, these are not the chief dangers which result from them. 
In many cases the thrombus does not entirely obstruct the wall of the 
vessel, and the blood circulates in the vessel beyond the thrombus. 
Even when the thrombus completely occludes the vessel, it extends up 
to the next collateral branch, and frequently beyond this, so that a por- 
tion extends into a vessel where the circulation is still taking place. The 
thrombi, further, are more frequently found in the venous side of the 
circulation than in the arterial. The chief danger from the thrombi is 
that portions may be washed off, carried into the circulating blood, and 
finally occlude arteries. The thrombi being more frequent in the venous 
system, the particles which are washed off from them occlude the ves- 
sels of the lungs. When thrombi are formed in the left side of the 
heart and in the arterial system generally, they will be carried into some 
other part of the circulation. The particles of the thrombus which 
may be broken off and enter into the blood-stream vary in size. The 
largest pieces come from the thrombi formed in aneurisms, from the 
heari^cavities, and from the large veins. These portions of the throm- 
bus which are carried by the blood-current to another portion of the 
body are called emboli. Where they will lodge depends upon the posi- 
tion of the thrombus. If they come from the veins, they will enter 
into the pulmonary arteries. Those from the arterial side — that is, from 
the left heart, the systemic arteries, and the lung-veins — are carried 
into the systemic arterial system, and those from branches of the portal 
vein into the branches of the portal vein within the liver. These 
emboli will be carried along by the blood-stream, and finally stop where 
the calibre of the blood-vessels is smaller than the diameter of the emboli. 
Virchow, and especially Eecklinghausen, have called attention to the fact 
that there may be a transportation of thrombi in a direction contrary to 



212 SURGICAL PATHOLOGY. 

the blood-stream. It is difficult to see how this takes place. It may be 
assisted by gravity, and it can only take place in parts where the circu- 
lation is exceedingly feeble and the blood-pressure in the veins very low. 
Large emboli can occlude the chief branches of the pulmonary arteries, 
or on the arterial side may occlude large arteries, such as the renal or 
iliac, or even the descending aorta. The smallest emboli may enter into 
the capillaries, and where the capillaries are relatively wide, as in the 
lungs, they may pass through these, and afterward plug up the narrower 
capillaries of the systemic circulation. It is evident that solid particles 
whose diameter is smaller than the capillaries can pass unhindered through 
all parts of the circulation. The emboli are apt to be found in places 
where the lumen of the vessel undergoes a sudden diminution in size, 
especially where large branches are given oif. 

It is not uncommon to find emboli entering into each branch of an 
artery at the place of its bifurcation. Such emboli are spoken of as 
riding emboli, situated as they are at the place of bifurcation, as in a 
saddle, with one leg in each division of the artery. The emboli almost 
always produce total occlusion of the vessel where they are found. They 
are carried with some force into the vessel, and being comparatively soft 
they will be pressed into it until they totally occlude it. The emboli 
may undergo the same changes as thrombi. They can become softened 
or they may organize. 

There may be special varieties of emboli which are not due to 
thrombi, but which are due to substances accidentally introduced into 
the vessels. Under certain conditions either air or a fluid which will 
not readily pass through the capillaries, such as oil, may be introduced 
into the circulation. A large number of cases have been reported of 
death in human beings attributed to the entrance of air into the veins. 
This accident has generally happened in surgical cases where operations 
have been done about the neck, shoulders, and skull. Further, death 
has occurred in cases in which air has entered the sinuses of the puer- 
peral uterus, generally in cases of criminal abortion in which air has 
been injected into the uterine cavity. In some of these cases death has 
been instantaneous, and in these there seems to be no reason to doubt 
that it has been due to the entrance of air into the circulation and the 
stoppage of large areas of the vascular territory of the lungs. A con- 
siderable amount of doubt, however, has been thrown on such cases by 
the result of experiment. It has been shown that the amount of air 
which is required to kill a dog if the air is directly injected into the 
vessels is much greater than could possibly enter the vessels in a sur- 
gical operation. If the air is injected slowly, enormous amounts can be 
injected without producing anything more than slight disturbances of 
the respiration and the action of the heart. In the cases in which death 
has been attributed to the entrance of air into the veins a large quan- 
tity of air or gas is found in the blood-vessels after death. Welch has 
shown that this is frequently due to the growth of an aerobic gas-pro- 
ducing bacillus in the blood. There is no doubt that a number of the 
cases which have been reported of death from air-embolism, in which 
death has taken place some time after the supposed entrance of air, have 
been due to infection with this bacillus, but there is equally no doubt 
that there have been cases of sudden death due to the entrance of not 



THROMBOSIS AND EMBOLISM. 213 

very large quantities of air into the circulation. The air is especially 
apt to enter into the veins if there is an inspiration at the same moment 
when a large vein, such as the jugular, is opened. When a large amount 
of air enters the heart at one time, death may quickly take place with 
evidences of suffocation. This is due to collection of air in the heart. 
The air is not forced out of the heart at each contraction of the ven- 
tricle, but is simply compressed. When a small amount of air enters 
slowly it will enter into the circulation, and may produce temporary 
occlusion of a number of the capillaries in the lungs. Unless the vas- 
cular territory so occluded is very large there will be little inconvenience, 
because the air will gradually be forced through the capillaries by sub- 
sequent contraction of the heart, and in a short while most of it will 
become absorbed. 

The presence of fat-emboli in the vessels of the lung has attracted 
considerable attention, but the importance of these emboli has been very 
greatly over-estimated. The fat of the body is in a fluid condition dur- 
ing life, the fat-cell representing a drop of fluid oil enclosed in a vesicle. 
When a number of these vesicles are broken, as in extensive crushing 
injuries, and the veins are ruptured at the same time, a certain amount 
of this fluid fat can enter into the circulation. It is especially apt to do 
this in injuries of the bones where there is not only a large amount of 
fat in the marrow, but where the veins are large and do not collapse. 
The fat entering the circulation in this way is nearly all stopped in the 
capillaries of the lungs, and may be found there at autopsies. It was 
at one time supposed that the shock after severe surgical injuries could 
be in large part explained by fat-embolism. It is rare, however, that 
the fat is present in sufficient amount to produce any serious results by 
occlusion of the capillaries. The collateral circulation in the capillaries 
is so abundant that no result can take place from the occlusion of a few. 
It is only when all of the capillaries of a very large area are occluded 
that any results will follow. 

The General and Local Effects of Thrombi and Emboli. 

An occluding thrombus in any portion of the venous system will lead 
to congestion and increased venous pressure in the vein behind the 
thrombus. The severity of the changes produced will depend upon the 
local conditions of the circulation in the part and the size of the vessel. 
If a large vein be occluded, it is evident that the consequences will 
be more serious than if the vein be a small one. Local conditions 
of the circulation affecting the results produced by a thrombus are 
due to the abundance or absence of collaterals. When there are two 
veins leading from a part with an abundant anastomosis between their 
branches, the occlusion of one of them will have no effect. The rapidity 
with which the thrombus is formed will also influence the result. If the 
renal vein be ligated, intense passive congestion of the kidney Avith hem- 
orrhage and necrosis results. Complete occlusion of the renal vein by 
a thrombus is sometimes seen Avithout producing any results. The 
thrombus is formed slowly, and time is given for the dilatation of the 
vessels of the collateral venous circulation, so that by the time the occlu- 
sion is complete these vessels are sufficiently dilated to carry off all the 



214 SURGICAL PATHOLOGY. 

blood from the kidney. The same thing is true of the portal vein. 
When this is ligated death results from the enormous distention of its 
branches. When it is slowly occluded by means of thrombus-forma- 
tion the few collateral branches dilate sufficiently to carry off the main 
portion of the blood, although the collateral circulation is rarely suf- 
ficient to prevent ascites and passive congestion. Sudden occlusion of 
the femoral vein in the neighborhood of Poupart's ligament is usually 
fatal. Intense congestion, cedema, and gangrene of the entire leg 
develop. When the occlusion takes place gradually by the slow forma- 
tion of a thrombus or by pressure of a tumor, no unfavorable conditions 
other than cedema to a greater or less degree may develop. 

The local effects of an embolus will depend to a certain degree upon 
the physical character of the embolus. Virchow found that when hard 
substances, especially those with irregular walls, were introduced into 
the circulation, they produced intense inflammation, frequently wdth rup- 
ture of the vessel at the point where they were arrested. W^herever an 
embolus lodges and whatever its character, it will always produce 
changes in the wall of the vessel in contact with it. The endothelium 
will become necrotic, and the necrosis may extend some distance into the 
surrounding tissue. Other local changes may be produced which do not 
depend upon the physical characters of the embolus, but upon its biologi- 
cal characters. The embolus may consist of living tissue, which may 
grow where it lodges. Particles of tumor are frequently carried by the 
circulation from a primary focus to a distant organ, and develop, forming 
secondary tumors where they lodge. Not only particles of living tissue, 
but living organisms, may be contained in the embolus, and these will 
produce the same lesions as in the place from which they were derived. 
This is especially seen in the emboli which come from the purulent soft- 
ening of a thrombus. In this way a secondary abscess may be formed 
around an embolus. 

The occlusion of an artery will produce effects in the tissue supj^lied 
by it. Here the effects produced will depend upon the presence or 
absence of collateral branches going to the same tissue. In certain 
parts of the body definite areas of tissue are supplied by definite 
arteries without anastomoses. Such terminal arteries are found in the 
kidneys, heart, and other organs. The effect produced will also depend 
upon the size of the artery. The collateral circulation may suffice for a 
small area, but not for a large one. There may be produced by the 
occlusion of an artery two conditions which are apparently widely dif- 
ferent. If the artery be a terminal one, the tissue supplied by it becomes 
necrotic. The form of necrosis produced is that described by Weigert 
as coagulation-necrosis, in which there is necrosis of the cells with 
coagulation. The anaemic part has a whitish, opaque character, and is 
generally triangular in shape, the apex of the triangle being formed by 
the occluded artery. Or a hemorrhagic infarction may be produced. In 
some cases hemorrhage takes place into the previous ansemic territory. 
The source of the blood in this case has been a matter of dispute. 
Cohnheim supposed that it was due to a backward flow from the veins, 
but this can be shown to be erroneous, because the infarction takes place 
when the veins are tied at the same time with the artery. The blood 
may have various sources. It is impossible by arterial occlusion to shut 



HYPERTROPHY AND REGENERATION. 215 

off all blood from a part. There are always anastomoses with the capil- 
laries of a neighboring part, and if the ansemic area be very small the 
capillary anastomoses will be sufficient to preserve the life of the tissues. 
The first effect of arterial occlusion must be to lower the pressure in the 
circulation distal to the occlusion. The pressure will be lower in all the 
vessels of the part, and the blood will flow into it from all the adjacent 
vessels. The blood-vessels become disteiaded and diapedesis of red cor- 
puscles takes place. If the amount of blood entering the vessels of the 
part is not sufficient to provide for a regular circulation, all of the tissue 
becomes necrotic. The diapedesis is generally supposed to be due to 
nutritive changes in the walls of the vessels, but it may be the result of 
changes which have taken place in the character of the blood. A combina- 
tion is frequently seen between hemorrhagic and anaemic infarctions. The 
centre of the infarction may be white and ansemic and be surrounded 
by a hemorrhagic zone. In this case sufficient blood does not enter the 
vessels to penetrate to the centre, or necrosis with coagulation may take 
place before it has sufficient time to do so. Various conditions of the 
body may influence the effects produced by an embolism. If the circu- 
lation is feeble and the general state of nutrition poor, the effect will be 
more disastrous. Embolism of the pulmonary arteries, unless the vessel 
be of considerable size, may not produce any effects. In the ordinary 
conditions of the pulmonary circulation there is sufficient capillary 
anastomosis, assisted by the anastomoses of the bronchial artery, to pre- 
serve the life of the tissue. In any embarrassment of the pulmonary cir- 
culation, especially in chronic passive congestion, infarction always results. 
That a part is able to retain its vitality after the occlusion of a large 
artery supplying it with blood is due to the development of the collateral 
circulation. After the ligation of the femoral artery below the point 
where the profunda is given off, the leg not only retains its vitality, but 
in a short time it will be able to perform all its functions as well as 
before. It must receive the same quantity of blood, and it cannot do 
this unless the other arteries dilate. No adequate explanation has been 
given for the dilatation which takes place. It cannot be explained on 
physical grounds, because tying the artery does not produce any increase 
of pressure in the branches given off above the ligature. The dilatation 
of the collaterals in this case is more complicated. Every tissue receives 
just the amount of blood which it needs for its nutrition and function, 
but no more. The varying amount is provided for by varying degrees 
of contraction of the muscular walls of the arteries. Where a small 
artery has to supply a large part with blood, it not only dilates to the 
fullest extent, but the calibre of the vessel actually grows larger. The 
dilatation is the result of the close relation between the calibre of the 
arteries and the needs of the tissue — a relation probably directly under 
nervous control. 

IV. HYPERTROPHY AND REGENERATION. 

In hypertrophy there is an increase in the size of an organ or part 
of the body, with retention of the normal structure. In regeneration a 
loss of substance in an organ or part of the body is restored by a tissue 
similar to that which is lost or which contains the same constituents. 



216 SURGICAL PATHOLOGY. 

A tissue can enlarge either by an increased power of assimilation or 
growth, or by diminution of the consumption of the tissue. Such a con- 
dition is physiological during the entire period of growth. When a part 
is growing, more tissue is formed than is used up. The normal size of 
organs and the general conditions of growth depend upon causes which 
are inherent in the germ. In order that growth may take place an 
abundant nutrition is necessary, which is provided in the intra-uterine 
life by the mother and in extra-uterine life by alimentation. The growth 
of the individual tissues and organs is dependent also on the activity of 
the blood- and the lymph-circulation. An extremity of a child ceases 
to grow, or it may even diminish in size, when for any reason the blood- 
supply is diminished. If all the conditions of nutrition are favorable, 
and if there are no general disturbing influences acting on the tissues, 
such as abnormal temperature, for instance, the development and growth 
of every individual take place at a rate corresponding to the age. The 
influence of the nervous system for such growth as this is not absolutely 
necessary. Examples of this are given in the monstrosities in which 
children are born without either brain or spinal cord. In these cases 
the body may sometimes show a development even in excess of the 
normal. The cells apparently from the beginning have the power of 
excessive reproduction — that is, reproduction in excess of the material 
used up — for a certain length of time, which difiers in different animals. 
This ceases in man at about the twenty-second year, and nothing can 
again excite it. This does not hold for certain tissues ; as, for instance, 
for muscles, for glands, and for the epithelial tissues generally. In these 
the power of forming new substance does not cease with the end of the 
period of growth. Every muscular contraction and every secretion of a 
gland takes place at the expense of the substance of the muscle and the 
gland ; and in order to supply this continual loss there must constantly 
be a new formation of contractile substance or of gland-cells. Even in 
the adult there may be an increase in the size of certain parts brought 
about by exercise and good alimentation. Arterial congestion, however, 
no matter how excessive, will not of itself produce an increased growth. 
Apparently the cells of the muscles and glands will only assimilate when 
they are stimulated, and congestion alone will not produce contraction in 
the muscle nor increased secretion in a gland. In other tissues assimila- 
tion and new formation apparently only depend upon conditions which 
govern the growth ; that is, the inherent power of reproduction and the 
degree of congestion. In all of these tissues an excess of production 
may take place when they are subjected to constant hyperasmia. Cohn- 
heim thinks that the growth of these tissues is due alone to the regula- 
tion of the blood-supply. He says that the bones and epidermis cease 
to grow at the end of the growth period, merely because if all the other 
organs of the body are supplied with blood in the proper measure, the 
quantity of blood which they receive will not be sufficient to excite 
growth. 

The increase of size of organs due to increased functional activity 
with increased blood-supply is familiar to us in the muscles and in 
the glands. When more work is thrown on the heart in consequence 
of increased pressure which has to be overcome, or in consequence of 
lesions of the valves, that portion of the heart which is called upon to do 



HYPERTROPHY AND REGENERATION. 217 

an increased amount of work becomes enlarged. An enlargement of the 
muscular walls of the bladder, which relatively can exceed that of the 
heart, takes place ^vhen, because of stricture of the urethra or enlarged 
prostate, it is forced to do a greater amount of work in expelling its 
contents. The same thing may be seen in the glands. When one kidney 
is destroyed, the other can undergo such an increase in size and weight 
that it will correspond to both kidneys and properly perform the func- 
tions of two. In other glands which are not necessary for the life of 
the individual, but only for the preservation of the species, as the testicles 
in man and the ovaries and mammary glands in the female, such a com- 
pensatory hypertrophy does not take place at all or only to a very limited 
degree. Hypertrophy only occurs when in consequence of the loss of one 
organ a greater amount of work is thrown upon another organ ; and this 
will not be the case for the testicle or the ovary. Extirpation of a part 
of the thyroid gland will lead to an increased size of the part which 
remains ; not only that, but other glandular structures which probably 
have the same function will also undergo an increase of size after extir- 
pation of a part of the thyroid An increase in the functional activity of 
one portion of one lung in consequence of inactivity in other portions 
will simply produce a distention of the alveoli of the lung which may lead 
to atrophy instead of hypertrophy. In general, the younger the tissue 
the more readily will compensatory hypertrophy take place. In tissues 
which are constantly being used up a diminished consumption may also 
produce hypertrophy. For instance, in the epidermis and the nails 
there is constant consumption of the horny layer, and anything which 
interferes with this constant rubbing off may lead to pathological thick- 
ening. The removal of pressure from tissues can also lead to new form- 
ation of tissue. The inner surface of the skull can become thickened 
when the growth of the brain in childhood is inhibited. Frequently- 
repeated mechanical and chemical irritation of the tissue may lead to 
hypertrophy. Repeated irritation of the skin can lead to the production 
of callosities and corns. The continuous inhalation of dust can lead to 
development of connective tissue in the lungs, but this cannot be consid- 
ered as hypertrophy in the true sense of the word. It is rather a repro- 
duction of tissue to take the place of that which was lost, and the new 
tissue has not the same structure and function. The cause of hyper- 
trophy in many cases is entirely unknown. 

Formerly a sharp distinction was made between hypertrophy and 
hyperplasia. By hypertrophy, strictly speaking, we understand an in- 
crease in the size of an organ due to an increased size of its constituent 
elements, without any new formation. In hyperplasia there is a new 
formation of tissue. These terms can be used interchangeably, for in 
hypertrophy there is always hyperplasia. It cannot be always assumed 
that when an organ is increased in size there is at the same time increased 
functional capacity, because the hypertrophy may not concern all parts 
of the organ. When a gland is increased in size, this may be due to an 
increase in all of the elements of the gland, or only the connective tissue 
may be increased in amount. This imperfect new formation of tissue 
can reach such an extent that hypertrophy may take place in one tissue 
of the gland while the other part undergoes atrophy. In such cases it 
is generally the specific constituents of the tissue, the ganglion-cells, the 



218 SURGICAL PATHOLOGY. 

nerves, the gland-cells, etc., that are atrophied, while the connective tissue 
increases in amount. One of the most striking examples of this is seen 
in the pseudo-hypertrophy of the muscles. Although the muscles appear 
to be enormously increased in size, this is not due to an increase in the 
contractile substance. Hypertrophy may also take place in the period 
of embryonic development or during the period of extra-uterine growth 
without our being able to assign any cause whatever for the increased 
growth of the tissue. 

The power of regeneration in tissues is always more or less limited. 
The more highly developed the tissue, the more its elements are differ- 
entiated for particular functions, the less complete is the regeneration. 
In the lower animals the power of regeneration exists io a very much 
greater extent than in man. Whole extremities of crabs and lobsters 
can be regenerated, and even in the lower vertebrates the same power 
exists. The younger the animal the greater the power of regeneration. 
In man the power of regeneration is limited. Whole pieces of tissue 
built up of complex elements, such as a finger or portion of the brain 
which is lost, do not regenerate. In adults the ganglion-cells of the 
nerve-centres have no power of regeneration. In the highly-developed 

§ lands the power of regeneration exists to some degree, but is limited, 
ingle cells of the gland when lost are easily replaced by multiplication 
of surrounding cells, but when large areas are lost the structure of the 
gland is only imperfectly reproduced, and granulation and cicatricial 
tissue take the place of the lost substance. The surface epithelium, the 
epithelium of the glandular ducts, the connective tissue, and the nerve- 
fibres have the power of regeneration to a marked degree. 

When a tissue whose elements correspond to the normal, but which 
does not perfectly agree with the type of the tissue in which it has devel- 
oped, is produced in a part, such a new formation is called a heteroplasia. 
For instance, a cicatrix in the liver represents a heteroplasia, because, 
although it is composed of connective tissue and may contain typical 
glandular elements, its whole structure does not agree with the structure 
of the liver, although this also contains connective tissue and glandular 
elements. The connective-tissue h^'perplasia which takes place in the 
course of inflammation may also be regarded as heteroplasia. There is 
also a condition known as heterochronia ; that is, a tissue may be formed 
which represents a normal type at a certain period of development, but 
which no longer conforms to the normal type. Hypertrophy and regen- 
eration are always associated with an increase in the number of the con- 
stituent elements. Increase in size of an organ may be brought about 
by a simple increase in the size of the single cells, but this does not play 
any part in pathology. 

The division of the cells which leads to a new formation of tissue is 
characterized by peculiar processes which take place in the nucleus and 
protoplasm. Recent investigations have shown that both the body of 
the cell and the nucleus possess a complex structure. In both the "pro- 
toplasm and in the nucleus a thread-like structure can be distinguished 
which encloses more or less numerous granules, some of Avhich have a 
perfectly definite form. Sometimes these threads are so arranged as to 
form a reticulum or sponge-work in the tissue. In the nucleus a thread- 
like reticulum is formed, and the points where the threads join form the 



HYPERTROPHY AND REGENERATION. 219 

granules. In various places the nodal points are larger and more 
marked. This same fibrilla structure is more condensed around the 
outside of the nucleus and forms here a sort of membrane. In the cell 
itself much the same structure can be recognized, but the granules and 
threads in the cell stain differently from those in the nucleus. The 
division of the cell is preceded by changes both in the protoplasm and 
in the nucleus. The chromatin of the nucleus becomes arranged in a 
different manner, and this change in the nucleus seems to be preceded 
by changes in a peculiar body iu the cell-protoplasm, known as the 
centresome. This body apparently divides first, and the two granules 
become arranged on either side of the nucleus. An unstained, spindle- 
formed structure extends from this both into the cell and into the 
nucleus, and then the various changes in the nucleus take place. Divis- 
ion of the cell so brought about is known as the karyomitotic, or the 
indirect cell-division. It was at first supposed that this was the only 
way in which cell-division took place, but there is also a direct division 
of the nucleus. This form of cell-division is seen both in the leuco- 
cytes and in the lymphocytes. 

The formation of new cells is the first stage in regeneration. The 
new cells provide the formative tissue from which the typical tissue of 
the part is developed. In the regeneration of tissues the different 
embryonic tissues only produce the same tissue. The epithelial cells 
can under no circumstances produce cartilage or bone, nor is a connec- 
tive-tissue cell able to produce either the surface or the glandular epi- 
thelium. This law was formerly not so clearly known, and many 
authors believed that the most different tissues could be formed from 
connective tissue. In the formation of the epithelial tissues the cells 
become united to one another by intercellular substance, the structure 
conforming to the type of the normal tissue. In the formation of con- 
nective tissue the most prominent feature is the formation of intercellular 
substance from the cells, and the character of this intercellular substance 
gives the various connective tissues their peculiar properties. In order 
that hypertrophy or regeneration of the tissue may take place the cells must 
have the power of multiplication. Most of the cells of the body possess 
this power, but others seem to have apparently lost it. These are cells 
which in the course of development have undergone a marked differentia- 
tion. The more the protoplasm of the cell departs from the type of the 
embryonic cell by differentiation for specific purposes, the more does it 
lose its power of regeneration. The horny layers of the epidermis, the 
non-nucleated red blood-corpuscles, the ganglion-cells of the brain of an 
adult, all seem to have lost their power of multiplication. The more 
indifferent cells, such as the connective-tissue cells, those of the bone- 
marrow, of the spleen, of the lymph-glands, and certain of the epithelial 
cells, have retained this power to a marked degree. 

The power of multiplication is one inherent in the cells themselves, 
and even when separated from their surroundings and placed in new 
localities they are still able to proliferate. On this power of growth 
depends the possibility of the successful transplantation of tissue ; that 
is, the transference of a piece of tissue from one place into another part 
of the body. Pieces of the periosteum or of the bone-marrow have 
been placed in various parts of the body or in blood-vessels, and have 



220 SURGICAL PATHOLOGY. 

there grown and developed normal tissue. The experiments which John 
Hunter made in transplanting the spurs of young cocks into the comb, 
where they grew more actively than in their normal situation, are well 
known. The tissue most frequently used for transplantation is the skin, 
and this method may be used to make up even large losses of substance. 
The great power of reproduction in embryonic tissues has been 
shown by experiments in the transplantation of tissue. The cartilage 
of an adult animal either does not grow at all or makes a very feeble 
growth when transplanted to new tissue. Portions of embryonic carti- 
lage so transplanted lead to an excessive growth. Leopold and Zahn 
transplanted pieces of embryonic cartilage into the anterior chamber of 
the eye and obtained a considerable new formation of cartilage. The 
transplantation of tissue must be done in animals of the same species, 
because the blood-serum and tissue-juices of an animal of one species 
generally have a poisonous action on the cells of an animal of another 
species. The transplanted tissue must also have a certain amount of 
cohesion and firmness, otherwise the intercellular substance will be dis- 
solved out and the tissue destroyed. It is probable also that the cells 
need contact with the adjoining cells — that they derive mutual sup- 
port from each other in their efforts to live in strange surroundings. 
In general, the growth of the tissue transplanted is limited. This is 
especially the case with pieces of tissue which are implanted deeply 
in the body. Growth only goes on for a certain time ; it then ceases, 
and the cells may disappear by absorption. As a rule, transplantation 
of the skin is not only the most useful, but is the most successful. The 
transplantation of skin can be made both on fresh and granulating 
wounds, especially on wounds which are covered with vascular, actively- 
growing granulations. Large thin pieces of skin which have been cut off 
with a sharp knife, and which consist of only the epidermis with the cut 
ends of the papillae or only the upper portion of the corium, may be 
placed on fresh granulating wounds and kept moist. The adhesion of 
the tissue takes place by means of the lymph or blood. After about eight 
days the transplanted tissue becomes firmly united with the tissue beneath. 
Portions of the tissue may be kept for several hours in normal salt^solu- 
tion before they are used for transplantation. The nutrition of the trans- 
planted piece of tissue appears to take place first by means of the imbibi- 
tion of nutrient material from the juices of the tissue. Later, a germinal 
tissue bearing blood-vessels grows up into the transplanted tissue. In 
some cases it appears to be evident that a direct connection is formed 
between the blood-vessels of the transplanted tissue and those of the 
old tissue. It is hardly possible to suppose that the transplantation of 
large parts — such as the entire finger, for instance — would be successful 
were this not the case. It would appear impossible for an entire finger 
to receive sufficient nutriment by means of imbibition to keep alive. 
Before new blood-vessels could grow from the base of the finger into 
the severed part necrosis would certainly take place, yet we know that 
portions of the finger, and even entire fingers, may be cut off and kept 
for some time, and then be successfully replaced. When the surface 
epithelium is transplanted the horny layer is cast off, and the adhering 
tissue at first consists only of the lower layer of germinal tissue, upon 
which a new horny layer is formed. 



HYPERTROPRY AND REGENERATION. 221 

The process of pigmentation in the skin has been studied by means 
of the transplantation of epithelium. It has been found that when the 
skin of a white man is transplanted on a negro the transplanted skin 
soon becomes pigmented, and the pigmented skin of the negro loses its 
pigment when transplanted on a white man. This experiment shows 
clearly that the skin-pigment is not formed in the epithelium, but is 
derived from cells in the tissue beneath, which have the physiological 
power of forming pigment. 

The question as to the cause of pathological new growth of tissue in 
regeneration and the conditions necessary for it to take place is quite 
obscure. One of the theories with regard to this, and which appears to 
be very plausible, is that the cells of the tissue have an inherent power 
of growth whicli is held in check by their relations to the surrounding 
tissues. When this relation is altered in any way, as when a loss of 
substance takes place, the cells in the vicinity, having the, inhibitory 
influence of the surrounding tissues removed, proliferate actively. Other 
observers believe that the cells have a certain irritability, a power of 
action which may take the form of growth, and under the influence of 
certain conditions of irritation they may be excited to growth. 

Among the influences which increase the capacity of proliferation of 
the cells, and which lead to a new formation of cells, increased nutri- 
tion brought about by hypersemia has an important place. It is certain 
that this congestive hypersemia makes possible an increase in the nutri- 
tion of the cells. It is probably necessary for cell-pi'oliferation, but it 
is not probable that this alone leads to proliferation. The cells are not 
nourished, but they nourish themselves. In general, it is probable that 
proliferation of the tissue in regeneration should be regarded as a second- 
ary process which in most cases depends upon a removal of the restric- 
tions of growth. In various attempts which have been made to excite 
growth by chemical and mechanical irritation a lesion of the tissue, a 
trauma of some sort, is always produced. It may take the form of a 
direct loss of substance or of necrosis. The regenerative changes which 
take place in the epithelium are relatively simple. Division of cells 
takes place by means of karyokinesis, and may be easily studied. In 
epithelium composed of several layers cell-division appears to take 
place only in the cells of the deepest layers near the blood-vessels. 
These cells are always younger than the others, and their protoplasm 
has undergone no differentiation. The formation of keratin, represent- 
ing a differentiation of the cells of the skin, only takes place after the 
cells have been produced a certain length of time and are I'emoved a 
certain distance from the centre of growth. 

In the regeneration of any tissue the new formation of cells does not 
seem to take place from any part of the tissue at random, but only from 
certain portions of the tissue. This was first studied by Flemming in 
the lymph-gland, and he found that in the gland there are certain cen- 
tres of growth which he described as the " keimcentren." In the liver 
such places are seen in the periphery of the lobule, and in the skin in 
the lower layers of the epithelium. It is very probable that this is due 
to more favorable conditions of nutrition of the cells in these centres 
of growth, but it may be that in these places certain cells retain their 
embryonic power of growth. The newly-formed cells frequently have 



222 SURGICAL PATHOLOGY. 

not the same morphological and functional character as the old, and may 
approach the embryonic type. In the new formation of epithelium^ in 
the lungs which takes place in chronic inflammation accompanied with 
extensive loss of epithelium lining the alveoli, the newly-formed cells 
in the alveoli frequently have the character of columnar cells. On sur- 
faces which are lined with ciliated epithelium the newly-formed cells do 
not acquire cilia for some time, and in the place of ciliated epithelium 
pavement epithelium may be formed. This is frequently seen in the 
healing of ulcers of the larynx and trachea. Small losses of substance 
in the surface epithelium are usually quickly replaced by growth of the 
epithelium in the neighborhood. 

Loss of substance in the glandular epithelium is quickly replaced in 
case the structure of the gland is not altered. Thus in the kidney the 
loss of single cells in the epithelial tubules after inflammation accom- 
panied by desquamation is quickly restored by regeneration proceeding 
from neighboring cells without any permanent lesion being produced. 
If, however, the structure of the tissue is destroyed and the relation 
with the surrounding tissues altered, complete regeneration is not apt to 
take place, and the site of the loss of substance is occupied by cicatricial 
tissue. In glands in which two sorts of epithelium are found — as the 
liver, for instance, in which we find both liver-cells and bile-ducts — in 
cases of loss of substance, regeneration takes place more readily and 
more extensively from the bile-ducts than from the liver-cells. The 
epithelium lining the bile-ducts is of the same character as that of the 
liver-cells, and represents a condition more nearly approaching the 
embryonic state. In some cases after loss of substance in glands a new 
formation of gland-tissue takes place in the same way as in the embryo. 
In the compensatory hypertrophy of one gland which follows the loss 
of a gland of similar structure and function there may be both an 
increase in the size and function of the epithelium of the remaining 
gland and also a new formation of tissue. This has been studied in the 
growth of one kidney Avhich follows after removal of the other, but it is 
not yet fully understood. It is not certain whether there is a new for- 
mation of complex structures in the kidney, such as the glomeruli, or 
whether these simply increase in size and in functional capacity. If 
new glomeruli are formed, this could only take place by a general return 
of the tissues to the embryonic condition. New tubules must be formed, 
and at the end of these glomeruli must be produced in the same manner 
as in the embryo. In the growth of the kidney which takes place 
before the adult size of the organ is reached there does not seem to be 
any new formation of glomeruli, which simply undergo an increase 
of size. The younger the kidney, the smaller the glomeruli. In the 
epithelium lining the intestinal canal extensive processes of regeneration 
may take place. In the healing of large typhoid ulcers of the intestine, 
just as in the healing of ulcers of the skin, there is a new growth of 
epithelium which extends from the edges and covers over the loss of 
substance. In the newly-formed epithelium the simple glandular crypts 
are produced, but the more highly differentiated structures, such as the 
villi, are not. The newly-formed glands are not so numerous nor do 
they have the same typical structure as in the normal intestine. 

Sometimes in the process of epithelial regeneration the new forma- 



HYPERTROPHY AND REGENERATION. 223 

tion of tissue may be far in excess of that necessary to supply the defect. 
The epithelium in every part of the body, especially the surface epithe- 
lium, has an almost unlimited power of growth. If there is a deiinite 
change in the character of the connective tissue beneath it — if the nor- 
mal connective tissue, for instance, is replaced by a tissue containing 
great numbers of cells with a small amount of loose intercellular sub- 
stances — the epithelium grows downward into such a tissue. At the 
edges of ulcers of the skin this atypical growth of epithelium may take 
place to such an extent that the structure of a typical epithelial carci- 
noma may be produced. The growth of the epithelium only extends 
into the pathological connective tissue, and the normal tissues are not 
invaded by it. In cases of intestinal suture the epithelium of the crypts 
of Lieberkiilin grows downward through the suture, and an extensive 
growth, resembling an adenoma and extending even to the peritoneum, 
may take place. 

In all processes of regeneration new formation of blood-vessels plays 
an important part, because only by a new formation of blood-vessels 
can the excessive nutrition which is necessary for regeneration be 
brought about. New blood-vessels will be formed even in non-vascular 
parts, as in the cornea. The new formation of blood-vessels has been 
sufficiently considered in Inflammation. 

The different members of the connective-tissue group show a marked 
difference in their respective powers of regeneration, which are most 
active in the periosteum, the bone-marrow, and the lymphoid tissue. 
The cartilage, on the other hand, is capable of only a slight power of 
regeneration. On the second day after fracture of bone the cells in 
the vicinity of the fracture enlarge and multiplication begins. In the 
physiological regeneration of tissue the newly-formed cells take the 
place of the old. It is simply a growth of the old tissue, without any 
intermediate steps and without any alterations of structure. When a 
large amount of young tissue is formed in a short time, the character 
of the old tissue is not immediately reproduced, but the growing cells 
and the blood-vessels form a germinal tissue which is usually known as 
granulation tissue. The extent to which this is produced varies in dif- 
ferent cases, and depends upon the capacity of growth of the tissue on 
the one hand and the extent of the lesion on the other. After fracture 
of bones an excessive amount of this germinal tissue may be produced. 
The growing cells are larger and richer in protoplasm than the cells of 
the old tissue. They may have one or two nuclei, and sometimes cells 
with numerous nuclei, the so-called giant-cells, appear. All the cells 
may unite in the formation of the future tissue. When connective tissue 
develops from such cells they are known as fibroblasts or inoblasts. 

The formative cells of cartilage and bone have received the name of 
chondroblasts or osteoblasts. The most varying forms of cells are seen 
in the forming connective tissue. The first step in the formation of 
the definite tissue is seen in the appearance of fine fibrillar bundles 
between the cells, or a homogeneous intercellular substance may be 
formed which afterward becomes differentiated into fibrillse. The for- 
mative cells increase in size, and finally lie in small spaces in the tissue. 
In the development of hyaline cartilage a hyaline ground substance 
appears between the cells, and the chondroblasts assume a round form. 



224 SURGICAL PATHOLOGY. 

As the ground substance increases these cells become smaller, and finally 
lie in round spaces, the wall of which forms the capsule of the cartilage- 
cell. 

The formation of new osseous tissue is a very complex process. In 
this a homogeneous or fibrinous substance forms between the cells, and 
afterward becomes infiltrated with lime-salts. The forming cells become 
smaller, and finally lie in small irregular cavities, and are designated as 
bone-cells. When there is an abundant formation of germinal tissue 
this direct change of the tissue into bone is limited. Within the ger- 
minal tissue an irregular meshwork of firmer tissue may appear, due to 
the formation of firm homogeneous tissue between the cells. This is at 
first not calcified, and is known as osteoid tissue. Afterward the inter- 
cellular substance becomes impregnated with lime-salts. The newly- 
formed osseous tissue is very extensive, being softer and looser in struct- 
ure than the old bone, and the gradual conversion of •this newly-formed 
tissue into a tissue similar to that of bone is quite a slow process. 
Mucous tissue is formed from the germinal tissue by the formation of 
homogeneous, gelatinous, intercellular substance which contains mucin. 
Mucous tissue frequently represents a transitory stage of growing con- 
nective tissue, and it may be afterward converted either into fat or into 
fibrillar connective tissue. Adipose tissue may develop in places which 
normally contain fat or it may form in any of the connective tissues. 
The regeneration of the blood is a process which is not well understood, 
in spite of the frequency with which it takes place. The blood is a 
very complex tissue, containing a number of elements of different 
origin. The formation of the round mononuclear cells of the blood 
takes place in the lymphatic glands, and these cells are simply taken 
into the blood from these glands. We know very little about the for- 
mation of the polynuclear leucocytes. This takes place in the bone- 
marrow and in the spleen, but the various steps connected with it are 
not known. There are cells in the blood which are regarded as pro- 
genitors of the polynuclear leucocytes, though the number is too small 
for us to regard them as the only progenitors of these cells. The new 
formation of red corpuscles is better understood. It is supposed that 
they are formed in the bone-marrow from certain cells which are called 
erythroblasts, by conversion of the protoplasm of the cells into the red 
corpuscle, the nucleus becoming extruded. 

New formation of muscular tissue takes place only to a limited 
extent after loss of substance. The increase of size of the muscles in 
hypertrophy is principally due to increase in size of the muscular fibres. 
After injury or loss of substance in the muscle the muscle-nuclei become 
elongated and divide. The cells of the connective tissue and sarcolemma 
also show rapid proliferation. The substance of the muscle between the 
nuclei becomes broken up into larger and smaller masses, so that the 
muscle-cells lie in spaces between these fragments. The fragments are 
absorbed, and a new formation of muscular tissue takes place from the 
newly-formed cells. The process is quite a slow one, and is frequently 
not completed until two months after the injury. When the loss of 
substance is extensive there is never sufficient new formation to com- 
pletely supply the defect, and the gap is occupied by connective tissue. 

Eegeneration of the cellular constituents of the central nervous system 



DEATH; NECROSIS; ATROPHY; DEGENERATION. 225 

does not take place in man, or in the mammalia generally, in post-embry- 
onic life. When there is a small loss of substance in the central nervous 
system a formation of connective tissue takes place ; if the loss is large, 
a cyst is formed. New formation of nerve-fibres of the peripheral ner- 
vous system is frequently seen. It takes place in all cases when nerve- 
fibres are cut across or in any way partially destroyed. Degeneration 
always takes place in the peripheral part of the nerve-fibre after section 
or injury of any sort. The central part, having a connection with the 
nerve-cell, preserves its vitality, and from this growth takes place. 
Regeneration begins in the central stump of a nerve a very few days 
after section, taking place by a growth of the axis-cylinder of the cen- 
tral end of the nerve. When the peripheral degenerated nerve is in 
contact with the central end, the growing fibres will extend along the 
old nerve to its muscular or sensory distribution. The presence of the 
old nerve gives the proper direction to the growing fibres. If the grow- 
ing axis-cylinders do not reach the old nerve, they may extend for some 
distance in the connective tissues, but more usually they either undergo 
atrophy or take various directions into the surrounding tissues and are 
finally lost. Regenerative processes may also take place in the central 
ends of the nerves after amputation. The regenerative growth may be 
considerable, and large masses composed entirely of a convolution of 
rolled-up nerves may appear on the cut ends of the nerves. These are 
called " amputation neuromas," and frequently give rise to a great deal 
of pain. 



V. DEATH; NECROSIS; ATROPHY; DEGENERATION. 

The tissues of the body are only capable of existing and preserving 
their function for a certain length of time. Their power of regenera- 
tion becomes less and less as age advances, and finally the regenerative 
processes are no longer able to keep pace with the rapidly-advancing 
processes of degeneration. Death from old age may be attributed to the 
gradual wearing out of the organs and the gradual loss of resistance 
which the dimiaution of the powers of regeneration entails upon them. 
Life ceases with the gradual destruction of the function of one organ 
after another. Destruction of the function of the heart, of the lungs, 
or of the nervous system produces death in a very short time. After 
destruction of the function of the intestinal canal, of the liver, or of the 
the kidneys the organism as a whole is just as certainly deprived of life, 
but some time may elapse before death takes place. 

In contradistinction to this general death of the organism the local 
death of a part, or of single cells or groups of cells, is called necrosis. 
With the appearance of this local death or necrosis, affecting groups 
of cells or an entire organ, changes of structure take place. These 
changes of structure occur so gradually that it is impossible to deter- 
mine the exact moment when the cells cease to live, and frequently in 
the early stage of necrosis neither the microscopic nor the macroscopic 
appearance is sufficient to tell us whether necrosis has taken place. The 
causes of necrosis of the tissue are various. The tissue may be destroyed 
by direct mechanical or chemical action. A finger can be crushed by 

Vol. I.— 15 



226 SURGICAL PATHOLOGY. 

external violence ; a portion of the skin may be destroyed by sulphuric 
acid ; and germs may destroy tissue in which they develop. The thermic 
death-point of protoplasm lies between 54° and 60° C. If tissues are 
exposed to this degree of heat for a short time, necrosis is produced. 
Lowering the temperature does not seem to exert the same unfavorable 
influence. Even in mammals portions of the body may be completely 
frozen for a short time and afterward be restored to function. When 
the tissues do not receive the proper supply of blood their function and 
resistance may be impaired, and if the blood-supply be sufficiently 
reduced necrosis results. This form of necrosis is called anaemic 
necrosis. Examples of it are given in the various infarctions due to 
arterial occlusion. 

The neuropathic necrosis is due to interference with, or inhibition of 
the function of, the trophic nerves. Regeneration of the tissue and 
nutrition generally are largely under the control of the nervous system. 
Regeneration does not take place so completely when the nervous supply 
of a part is destroyed. Samuel found that when the long feathers of the 
wings of pigeons are pulled out they are only incompletely regenerated 
when the nerve of the wing has been cut. The supposed trophic influ- 
ence of the nerves, however, cannot be separated from the action of the 
vasomotor nerves which accompany them. As examples of necrosis due 
to interference with the functions of the trophic nerves the rapid and 
severe bed-sores which develop in the course of certain diseases, espe- 
cially after injury of the spinal cord, are cited. 

Any condition which in any way interferes with the circulation in a 
part, such as thrombosis, embolism, closure of vessels by continual tonic 
contraction, by lesions of the walls, by ligature, by pressure from with- 
out, inflammation, hemorrhage, etc., can produce necrosis. In certain 
tissues temporary cessation of the circulation lasting but a short while 
may produce necrosis. The various tissues have varying powers of resist- 
ance to disturbances of the circulation. In general, the more highly 
organized the tissue is, the more rapidly does it succumb. The epithelial 
cells of the kidney will undergo necrosis when the circulation is shut off 
for only one or two hours. The ganglion-cells of the central nervous 
system are also very sensitive. Other tissues can withstand the shutting 
oiF of the circulation for a very much longer time. The skin, the bone, 
and the connective tissues generally may live for ten or twelve hours 
after the circulation has been cut off. Cases have been known in which 
small portions of the body, such as the fingers, have united perfectly 
when replaced six hours after removal. If the circulation in the tissue 
is imperfect or its nutrition in any way interfered with, as in general 
marasmus or hydrsemia, it undergoes necrosis much more easily than a 
perfectly normal tissue. Necrosis takes place much more readily in old 
people and in those in whom the action of the heart is imperfect. In a 
part subject to chronic passive congestion or oedema a very slight cause 
may produce necrosis. Invalids who suffer from acute diseases, partic- 
ularly typhoid fever, may have extensive necrosis from comparatively 
slight pressure on projecting parts. 

In consequence of necrosis of a tissue a more or less extensive inflam- 
mation is produced in the surrounding parts. This is more intense when 
putrefactive processes take place in the necrotic tissue, which exerts a 



DEATH; NECROSIS; ATROPHY; DEGENERATION. 227 

positive chemotactic attraction for the white corpuscles, which enter 
into it in large numbers. A zone of inflammation is set up which 
separates the necrotic tissue from its surroundings. The dead tissue 
may be gradually removed by absorption, or it may be cast off as a 
whole. A part of it may remain, which can afterward undergo calcifi- 
cation and remain in the tissues as a foreign body, and become sur- 
rounded by a capsule of connective-tissue formation, or a cyst may 
be formed in place of the necrotic tissue. This most commonly takes 
place in the brain, and it is also often seen in tumors. 

One of the most common forms of necrosis is that designated as coag- 
ulation-necrosis. This is necrosis with coagulation of the necrotic cells 
and the fluid surrounding them. Both the cells and the cell-derivatives 
after necrosis has taken place may become changed into peculiar homo- 
geneous, dense masses. Inflammatory exudations on a surface also unite 
with the necrotic cells of the surface and form masses of fibrin appearing 
as a membrane. The membrane consists partly of granules and partly 
of filaments, which are found united together to form thick meshes in 
the tissue. Large hyaline refractive masses can also form in this way. 
In this form of necrosis various changes take place in the cells. The 
nuclei first lose the normal arrangement of the chromatin, and become 
changed into solid masses which may stain more brightly than the nuclei 
of the normal cell. The nucleus appears solid and homogeneous. The 
nuclei afterward lose their sharp contour, become irregular, and finally 
break up into a mass of brightly-stained granules which may be recog- 
nized in the tissue as nuclear detritus. The best example of coagulation- 
necrosis is given in the infarction which takes place in various organs 
in consequence of the shutting ofl" of the blood-supply. The cells may 
retain their form for some time. They afterward become changed into 
finely granular, homogeneous masses which may undergo absorption. 
Coagulation-necrosis takes a special form in striated muscular fibres. 
When necrosis of muscular fibres takes place in consequence of crushing 
or tearing, or of elevation of temperature in certain diseases accompanied 
by high fever, the contractile myosin becomes stiffened, and frequently 
changes into refractive homogeneous masses which may entirely fill up 
the sarcolemma. This form of degeneration is spoken of as the " waxy " 
or Zenker's degeneration. This may take place in the individual fibres 
of a muscle or may involve large masses of a muscle. It is a total de- 
struction of the tissue, and is not capable of reparation. The affected 
muscles are of a pale grayish-red color somewhat similar to the flesh of 
fish, and have an opaque and dry appearance. This form of degeneration 
is frequently found in the muscles of the abdominal wall in typhoid fever. 
Hemorrhage usually takes place in the affected areas. 

Another form of necrosis is known as " caseation." This term refers 
solely to the appearance of the necrotic tissue, and is used to designate a 
form of necrosis in which the tissue changes into a substance resembling 
soft white cheese. The best example of this is seen in the necrosis which 
takes place in tuberculous products. This caseous tissue is more or less 
brittle, and appears as an opaque whitish or yellowish-white mass. Case- 
ation takes place when masses of cells with little or no tissue between 
them undergo necrosis. The consistency of the caseous tissue varies 
greatly. Sometimes it is firm and dry, sometimes comparatively soft. 



228 SURGICAL PATHOLOGY. 

Caseation cannot be regarded as a process peculiar to tuberculosis, 
although it is seen more often in tuberculosis than in any other condi- 
tion. It is also seen in tumors which are rich in cells and contain 
necrotic areas due to disturbances in nutrition, and in the pathological 
products of syphilis, but the caseation which appears in the course of 
syphilis has a rather different character from that seen in tuberculosis. 
The necrotic tissue may undergo liquefaction. It becomes saturated with 
fluid, and finally melts up, forming a fluid mass. In an anffimic necrosis 
of the brain the necrotic tissue breaks up into small granular masses, 
which are partly absorbed and partly dissolved in the circulating lymph, 
and a cyst filled with clear fluid takes the place of the necrotic tissue. 
Coagulation does not take place, because the brain is so poor in the 
elements necessary to fibrin-formation. The chemical products pro- 
duced in suppurative inflammation also have the power of dissolving 
necrotic tissue. 

A peculiar form of necrosis is that known as fat-necrosis, and in 
connection with disease of the pancreas it has received much attention. 
Small opaque masses are found in the fat in various places in the 
abdominal cavity. They vary in size from a microscopic point up 
to areas several millimetres in diameter. On section of the pancreas 
they are also seen in the connective-tissue septa running through the 
gland. Fat-necrosis is associated with various diseases of the pancreas, 
with hemorrhage, with acute suppuration, and with other conditions. 
It is held by some authors that the changes in the fat are primary, and 
that the lesions in the pancreas are due to necrosis in the glandular 
septa. It is held by others that the lesions in the pancreas are primary, 
and that the necroses of the surrounding fat are due to the action of the 
pancreatic juice which escapes into the surrounding parts. The distri- 
bution of the areas of necrosis gives some ground for this assumption, 
but it has not been confirmed by experiment. The necrotic areas in the 
fat are intensely resistant. They are not affected by mineral acids nor 
by caustic alkalies. The peculiar change in the fat is due to a combina- 
tion of lime-salts with the fatty acids. 

Mummification, or dry gangrene, is seen in the senile necrosis of the 
lower extremities and the toes, and in the necrosis following frost-bite. 
Senile necrosis is due to imperfect circulation in the part, resulting partly 
from general weakness of the circulation and partly from disease of the 
intima of the artery with thrombosis, or from embolism. In frost-bite 
the necrosis is produced by the influence of low temperature lasting for 
a considerable time. In both frost-bite and senile gangrene there is 
venous hypersemia while the necrosis is taking place. The necrotic 
tissue is filled with blood, and by the diffusion of the blood-coloring 
matter the necrotic part acquires a dark-red or black appearance. 
Vesicles are formed which rupture. The entire epidermis of the part 
may be removed, evaporation goes on rapidly, and the part becomes 
changed into a dry, hard mass with a leathery surface. A sharp line of 
demarcation is established between the healthy and the gangrenous tissue, 
and the gangrenous part may be gradually separated from the living 
tissues by suppuration and softening. The inflammatory exudation exerts 
a dissolving action on the necrotic tissue. The separation takes place 
readily through the soft parts, and in the course of time may extend 



DEATH; NECROSIS; ATROPHY; DEOENEBATION. 229 

through the bones. Moist gangrene, or sphacelus, is charaoterized by- 
decomposition or putrefaction in the necrotic tissue. This takes place 
when the organisms of putrefaction enter into a gangrenous part which 
contains a large amount of fluid. The gangrenous part may have its 
temperature elevated, this being due both to the process of decomposition 
and to a surrounding inflammation; and this condition is known as "hot 
gangrene." The putrefactive tissue soon begins to emit a foul odor and 
becomes broken down. Sometimes the process of decomposition is accom- 
panied with the formation of gas, which may infiltrate the tissue. The 
various tissues of the gangrenous part show different degrees of resistance 
to the process of putrefaction. The bone may remain for some time, while 
the soft parts are rapidly broken down. The tendons and large arteries 
are also relatively resistant. On microscopic examination there are nu- 
merous bacteria present, most of which belong to the anaerobic forms. 
The blood-corpuscles become dissolved, broken up, and converted into 
masses of granular pigment. The fat-cells are broken down, and the fat 
appears in the form of small drops in the tissue. There are various 
crystalline products of this decomposition. We may find crystals of the 
fatty acids in the form of long needles, the needle-shaped crystals of 
tyrosin, the globular masses of leucine, and the coffin-shaped crystals of 
triple phosphates. 

Hypoplasia is the condition in which portions of the body, or single 
organs or parts of organs, have an imperfect form of development in 
consequence of inhibition of growth. This may be due to intrinsic causes 
in the organs themselves resulting from imperfection in the germ, or 
it may be due to the influence of external causes. When organs or 
parts of organs are entirely absent, the condition is known as aplasia or 
agenesis. Examples of hypoplasia are seen in imperfect growth of the 
bones and in imperfect development of the heart or large vessels or 
of the genitalia or the central nervous system. The normal gradual 
development of a part may be interfered with and a foetal condition of 
the organ result. The hypoplasia may affect organs which are necessary 
for life, or organs which serve some purpose not essentially connected 
with the preservation of the life of the individual. For instance, the 
genitals may remain in the fcetal condition or in that of early childhood. 
Hypoplasia may produce disturbances of function only, or it may be 
incompatible with life. 

The condition of atrophy is usually separated from that of hypo- 
plasia. Atrophy is a diminution in the amount of tissue, which takes 
place in an organ or part which has been normally developed. It may 
be due to an imperfect power of regeneration which cannot keep pace 
with the constant waste. Old age furnishes an example of this. There 
may be atrophy either of the entire body or of any of the individual or- 
gans or tissues of the body. An individual may die from old age without 
any preceding disease as soon as the atrophy of important organs reaches a 
condition which is incompatible with the proper performance of function. 
There is a physiological atrophy of certain organs which may take place 
in an early period of life. Certain organs which were necessary for life 
of the embryo undergo atrophy before birth. The sexual glands of the 
female may become atrophied and incapable of function long before the 
period of general senile atrophy is reached. The thymus gland atrophies 



230 SURGICAL PATHOLOGY. 

before the -completion of the period of growth. Anatomically, atrophy 
is usually characterized by diminution in size of an organ. Microscopi- 
cally, it is seen in the diminution in size, and finally the complete disap- 
pearance, of the specific elements of an organ. Atrophy may produce 
different appearances in different organs. In large organs rich in specific 
elements, as the liver, the kidney, the heart, and the brain, the diminu- 
tion in size is the most striking feature. If the atrophy is a general one, 
affecting equally all parts of the organ, the surface may remain smooth. 
If it takes place only in certain parts of the organ, it gives to the sur- 
face an uneven appearance. The atrophied portions will be depressed, 
and the normal portions will appear correspondingly elevated. There 
may be atrophy without any macroscopic changes in form. A bone may 
atrophy without any change in its external size or shape, the atrophy 
having taken place in the interior of the bone by enlargement of the 
medullary canal. The bones of old individuals may be little more than 
shells enclosing a large medullary cavity. Diminution in the size of 
atrophied organs is usually due to destruction of their specific elements. 
The connective tissue of the organ may not take part in this atrophy at 
all ; in some cases it may be even increased, so that an organ in which 
a considerable degree of atrophy has taken place may be of normal size 
or even larger than normal. This condition is seen in the pseudo-hyper- 
trophy of muscles. In the atrophy of the kidneys which takes place in 
old age or in various other conditions the epithelial cells of the urinary 
tubules gradually become smaller and finally disappear, and the tubules 
collapse. The epithelium of the glomerulus also becomes destroyed, the 
capillaries collapse, and finally the glomerulus is represented by a small 
hard mass of connective tissue. Fat often undergoes a peculiar change 
in consequence of atrophy. The fat in the cell breaks up into small 
drops which become absorbed, and the cells freed from fat become 
transformed into their original character as connective-tissue cells. 

Two forms of atrophy, active and passive, have been distinguished. 
In active atrophy there is a diminution in the capacity of growth and 
regeneration of the cells, in consequence of which they cannot assimilate 
the nutritive material which may be brought to them in the proper 
quantity. In passive atrophy the cells are capable of growth and 
regeneration, but there is a diminution in the amount of nutritive mate- 
rial which is brought to them. Both of these sorts of atrophy are fre- 
quently combined. Atrophy may be divided into senile atrophy, atro- 
phy in consequence of imperfect nutrition, atrophy from pressure, atrophy 
from disuse, and neuropathic atrophy. 

Senile atrophy may take place in all or any of the organs and tissues, 
but it is frequently more developed in some organs than in others. 
Organs such as the kidneys, the liver, the brain, and the heart can 
undergo very important diminution in size. Senile atrophy is also seen 
in the skin of old people, and this is one of the most common atrophic 
conditions produced by old age. The skin loses its firmness and elas- 
ticity and becomes thin and parchment-like. 

Atrophy in consequence of disturbed nutrition is produced by imper- 
fect assimilation. It may affect the entire organism or be more marked 
in certain tissues than in others. For instance, the fat of the body, the 
muscles, and the large abdominal glands show relatively a greater degree 



DEATH; NECROSIS; ATROPHY; DEGENERATION. 231 

of atrophy than the other tissues. Local atrophy may result from local 
interference with the circulation. An entire organ may undergo atrophy 
in consequence of diminution in calibre of its main artery brought about 
by disease, or only small branches of the artery may be affected, pro- 
ducing atrophy of circumscribed portions of the organ. Atrophy may 
be the result of pressure, even of comparatively slight degree, when it 
is constantly exerted. It is due partly to direct injury of the cells of 
the tissue in consequence of the pressure, and partly to interference with 
the blood-supply. The most typical example of this is seen in the broad 
band across the lower portion of the liver in women, corresponding to 
the line of the waist, and which is the result of the pressure of corsets. 
Sometimes this is so marked that there may be almost a complete sepa- 
ration of the lower portion of the right lobe of the liver from the rest. 
The atrophied part of the liver is marked by a thickening and roughen- 
ing of the surface due to increase in the connective tissue. The firmest 
tissue may give way before a constant pressure. For instance, the pres- 
sure by an aneurism on bone, as in aneurism of the aorta pressing upon 
the sternum or upon the vertebr£e, may produce complete atrophy and 
destruction of the bone. 

Atrophy from disuse is seen in all tissues whose ordinary functions 
are suspended. It is more marked in the muscles, glands, and bones 
than in any other parts. The atrophy is essentially an active one. With 
the diminution in function the capacity of the tissue for assimilation also 
diminishes. There is also diminution in the activity of the circulation 
in organs with imperfect function, and the atrophy may be in part due 
to this. When the disuse appears during the period of development, 
and when the part in consequence is imperfectly developed, the con- 
dition may be regarded as one of hypoplasia. No sharp line can be 
drawn between atrophy and hypoplasia, since the hypoplasia of tissue 
may be associated with destruction of tissues which have already been 
formed. One of the best examples of atrophy from disuse is seen in the 
diminution in size of paralyzed parts. 

Neuropathic atrophy is the result of pathological conditions of the 
nervous system. The best examples of neuropathic atrophy are seen in 
the atrophy of the corresponding nerves and muscles which follows 
atrophy of the anterior horn or anterior nerve-regions of the spinal 
cord. After injury of peripheral nerves the skin corresponding to their 
distribution may undergo atrophy and become thin and shinj\ Affec- 
tions of one side of the brain in foetal life and in childhood may produce 
atrophy of the corresponding portions of the face and body. In this 
condition the process is not usually one of simple atrophy without any 
preceding change, but is preceded by various forms of degeneration, 
of which the atrophy represents the last stage. It is due to interference 
with the vasomotor system by which every part of the body exactly 
regulates its nutrition. Disuse of the parts and the greater susceptibility 
to trauma may also play an important part. Even for this form of 
atrophy it is not necessary to assume the existence of special trophic 
nerves. 

Degeneration of Cells. — One of the forms of degeneration of cells 
is known as cloudy swelling, or parenchymatous or granular degeneration. 
The term was first used by Virchow, who regarded cloudy swelling as 



232 SURGICAL PATHOLOGY. 

an increase in the size of the cells produced by increased nutrition, or 
as hypertrophy with a tendency to degeneration, but the process is 
now regarded as degeneration. In cloudy swelling there is an increase 
in the size of the cells due to the accumulation of fine granules in 
the protoplasm. These granules are soluble in acetic acid and insoluble 
in caustic potash and ether. In consequence of the presence of the 
granules in the cells the nucleus is obscured, and it only becomes 
visible after the granules are cleared up by the addition of acetic 
acid. The process may be recovered from and the cells return to 
their normal state, or they may be converted into masses of granular 
material, and then break down and disappear. Fatty degeneration of 
the cells is frequently combined with cloudy swelling. It is best seen 
in the parenchymatous organs, such as the liver, the kidneys, and heart. 
It appears in most of the acute infectious diseases, especially in those 
which are accompanied with high fever. The affected organs have a 
cloudy, dull, grayish appearance. In the highest degree of the affection 
they look as though they had been boiled. The consistency is doughy 
and the minor details of structure are obscure. Cloudy swelling is fre- 
quently combined with a dropsical degeneration due to a swelling of 
the cells from the absorption of fluid. From the absorption of the fluid 
the interior of the cell appears clear and the granules of protoplasm are 
separated from one another and are sometimes pressed to the periphery 
of the cell. Such changes of the cells are found in oedematous tissue, in 
inflammatory foci, and in tumors. 

Cloudy swelling frequently passes into fatty degeneration. In this 
fat-drops are formed in the cells, which finally break up into masses of 
fatty detritus. Certain tissues of the body normally contain a varying 
amount of fat. These tissues represent a storehouse for fat, which is 
either introduced from without or forms in the organism and is deposited 
in these places. An increase of this fat is not regarded as fatty degen- 
eration, but as lipomatosis or obesity. Up to a certain degree it can be 
regarded as physiological. When it becomes excessive it represents a 
pathological condition. The deposit of fat takes place in the cells in the 
form of small drops, which gradually fuse together to form large globules, 
and finally a single large globule of fat may fill up the entire cell. The 
distinction which is made between lipomatosis and fatty degeneration is 
that in fatty degeneration the fat results from a destruction of the proto- 
plasm of the cells by its conversion into fat. In the process of nutrition 
fat is probably formed by the destruction of albumin, but in fatty degen- 
eration it is the albumin of the cell, and not the albumin of nutrition, 
which is broken up. Fatty degeneration especially takes place under 
conditions in which there is at the same time a tendency for the albumin 
of the cells to break down and a diminution of oxidation. It is fre- 
quently found in advanced phthisis, in which the oxidation in the tissue 
is greatly reduced on account of the destruction of lung-tissue. It is 
found in the varying forms of anaemia — both in the anEemia caused by 
direct loss of blood by hemorrhage and in other conditions in which the 
red blood-corpuscles are destroyed, causing a diminution in the amount 
of oxygen conveyed to the tissues. In the fatty degenerated cells there 
are larger and smaller drops of fat, which are colorless, dark, and re- 
fractive. When these drops are very small it is difficult to distinguish 



DEATH; NECROSIS; ATBOPHY ; DEGENERATION. 233 

them from the granules in the protoplasm seen in cloudy swelling, but 
on the addition of acetic acid the granules are cleared up and the fat 
can be distinguished. The number and size of the fat-drops in the cells 
vary, but in general the drops are very much smaller than we find them 
in the accumulation of fat. In some instances the fat accumulates in 
certain parts of the cell only. In fatty degeneration of the kidney the 
fat is formed in the periphery of the cells close to their insertion. The 
degeneration may not affect all of an organ, but only certain small areas, 
and these areas by their opacity and whiteness form a marked contrast 
to the surrounding tissue. Tliis is frequently seen in the heart and in 
the kidney. In the heart the alternation of the fatty areas with the more 
normal tissues gives to the organ a spotted appearance which has been 
compared to that of a leopard skin or of a faded leaf. Fatty degenera- 
tion may take place in the voluntary muscles in anaemia and in other 
cachectic conditions, but it is more often seen in cases of disuse. Muscles 
which have been for a long time paralyzed undergo various degrees of 
fatty degeneration — a fact which points clearly to the effects of dimin- 
ished oxidation. 

In certain conditions glycogen may accumulate in the cells in the 
form of round globules. It can be recognized by hardening the tissues 
in absolute alcohol and staining with iodine, which gives to the glyco- 
gen a brownish-red color. Glycogen is normally found in the liver, in 
voluntary muscles, in the myocardium, in the colorless blood-corpuscles, 
in blood-serum, in cartilage-cells, and in almost all embryonic tissues. 
In diabetes the epithelium of the kidney, especially the epithelium of the 
tubules of Henle, may contain glycogen. It may be present in various 
forms of tumors, especially in the epithelial cells of carcinoma, and is 
more generally present in carcinoma of the testicle than in carcinoma 
elsewhere. 

In mucoid or colloid degeneration there is a formation of material 
called mucus in the cells and in the tissues. The physiological type 
of this formation of mucus is seen in mucous membranes and glands, 
also in the tissue of the umbilical cord, in the various bursse, and in 
" synovial membranes. In mucous membranes the mucus is formed in the 
so-called goblet-cells. These are large swollen cells which have the 
appearance of a goblet, with a mass of mucus projecting from them. 
Apparently, this power of forming mucus exists in only certain of the 
epithelial cells. It may be increased under pathological conditions, as in 
catarrhal inflammation of the mucous membranes, in which there is an 
increased formation of clear mucus both in the surface epithelial cells and 
in the cells of the glands. Pus-corpuscles can undergo mucoid degenera- 
tion and mucin be formed in them. In certain tumors, as in the multi- 
locular cysts of the ovary, there is an enormous formation of mucin. 
With regard to the formation of mucin in connective tissue, Virchow 
believes that it is formed by a secretion of the cells and is analogous to 
the formation of fat. Koester believes that in the mucoid degeneration 
of the connective tissue there is no new formation of mucin. The appar- 
ently mucoid tissue is really cedematous connective tissue, and the mucin 
already present in the tissues is swollen up by the imbibition of fluid. 
The term " mucoid degeneration " is one which is rather loosely used, 
and it is probable that various forms of degeneration of connective tissue 



234 SURGICAL PATHOLOGY. 

are included under this general head. Colloid degeneration is closely 
related to the mucoid. Its product appears to be derived from the 
metamorphosis of albumin, although we know nothing definitely of the 
chemical processes of its formation. It is formed from the cells, and 
physiologically it is always present in the thyroid gland, giving to a 
section of this gland a gelatinous appearance. It appears first in the 
epithelial cells of the gland in the form of small globules. The entire 
cell may undergo this transformation, or the single globules may be 
ejected from the cells and unite to form a large colloid mass in the centre 
of the alveolus. 

A form of degeneration known as hyaline was first described by 
Recklinghausen. Its name indicates its most characteristic feature. 
It is a perfectly homogeneous material which has rather indefinite stain- 
ing reactions. It stains with eosin, with carmine, with picrocarmine, 
and with certain of the acid anilines. It has the same reaction to 
alcohol and various other agents as has the amyloid material, but it has 
not the characteristic stain with iodine which the latter has. It is very 
probable that the hyaline material embraces a number of different prod- 
ucts. It is found in certain epithelial tissues, where it is closely related 
to the colloid material, if not identical with this. In certain forms 
of nephritis a homogeneous, firm material accumulates in the urinary 
tubules and is passed from the kidneys, appearing in the urine as hya- 
line casts. This material has apparently been formed by a degeneration 
of the protoplasm of the cells, and appears first within the cells in the 
form of small homogeneous drops. There may be a similar process in 
the lungs. In certain forms of pneumonia in cattle the alveoli may 
become filled with firm, transparent, homogeneous masses. Large epi- 
thelial cells containing in their interior homogeneous globules may be 
found enclosed in the hyaline masses, which probably are derived from 
coalescence of hyaline globules formed in the epithelial cells. The 
material described as hyaline in some cases seems to be identical with 
or closely related to fibrin. It may appear in the form of homogeneous 
masses which entirely occlude small blood-vessels. This is frequently 
seen in the blood-vessels of the lungs in various infectious diseases, espe- 
cially in those due to infection with streptococci. It is also seen in the 
blood-vessels of the kidney, where it occludes the capillary vessels of 
the glomeruli. This form of hyaline material stains in the same way as 
fibrin, and it is probable that it is identical with it. The newly-formed 
connective tissue in chronic inflammations may be converted into a 
homogeneous, firm mass in which no cells are found. This is also spoken 
of as hyaline, but it must be regarded as entirely different from the other 
forms of hyaline. It is probable that we shall know little of these forms 
of degeneration until the chemistry of the process shall be in some way 
discovered. 

Amyloid Degeneration. 

Under certain conditions a peculiar albuminous substance, called 
amyloid, is deposited in the tissues. This deposition may take place in 
almost all the organs of the body, but appears most often, in the ordet 
given, in the spleen, the liver, the kidneys, the intestine, the stomach, the 
adrenal glands, the pancreas, and the lymph-glands. It is more rarely 



DEATH; NECROSIS; ATROPHY; DEGENERATION. 235 

seen in the adipose tissue, the thyroid, the aorta, the heart, the muscles, 
the ovaries, and the uterus. It may take place in organs which are the 
seat of some other disease or in those which were previously sound. 
The amyloid material is generally found along the small blood-vessels, 
especially in the walls of the small arteries. At first sight it appears as 
though the entire wall of the artery were converted into amyloid, but 
closer examination will show that the amyloid material is infiltrated 
between the muscle-cells. Though spoken of as a degeneration, it 
really is not produced by a metamorphosis of the tissue, but is an infil- 
tration which is deposited between the cells of the tissue and gradually 
produces atrophy in them. It is frequently combined with other forms of 
degeneration, especially the fatty. Even though an organ be sound when 
the deposit of amyloid first takes place, this deposit, from its position, 
situated as it is about the blood-vessels, will lead to such disturbances 
of the circulation and nutrition of the organ that other forms of degen- 
eration will occur. If a section of such an organ, either fresh or after 
hardening in alcohol, be treated with an aqueous solution of iodine, the 
amyloid material becomes a reddish-brown mahogany color, contrasting 
sharply with the normal tissue, which has a slight yellowish tint given it 
by the iodine. If amyloid material so stained be treated with a dilute 
solution of sulphuric acid or with chloride of zinc, the brown color some- 
times becomes more intensified or it may take a slight violet tone. A 
more direct reaction is given by any of the blue aniline colors, especially 
gentian-violet. Fresh sections of the aifected tissue may be placed in 
the coloring agent and afterward washed out in very dilute acetic acid. 
The amyloid substance acquires a brilliant red color, and contrasts 
sharply with the normal tissue, which has the ordinary blue stain. The 
situation of the amyloid in the walls of the arteries would seem to indi- 
cate that it is formed either in the blood or in some special organ, and 
afterward deposited in the walls of the vessels and in the tissues. We 
do not know, however, any organ in which such a formation could take 
place. The most prevalent view now held concerning it is that it is 
formed from the albumin in the place where it is found. The cells 
seem to lose their power of properly assimilating albumin, and it under- 
goes this peculiar form of degeneration. The conditions under which 
amyloid infiltration takes place are well known. It is always found in 
cachectic conditions of the body brought about by long-continued sup- 
puration or by certain chronic diseases. It is rather more frequent in 
syphilis than in any other disease, and it is rare that we find any exteii- 
sive visceral lesions of syphilis without finding a certain amount of 
amyloid in the tissues. It is especially apt to occur in the chronic 
affections of bone. The recognition of amyloid infiltration of tissues is 
very important. The nutrition and general resistance of the tissues are 
so impaired that surgical operations and injuries usually are not well 
borne. 

The amyloid material may also appear locally, producing localized 
infiltration of the tissue or solid accumulations of amyloid. Large 
nodules which are entirely composed of amyloid may form in the tissues. 
Such nodules have been seen in the inflamed conjunctiva, in syphilitic 
cicatrices of the liver, in the tongue, in the larynx, and in inflamed 
lymph-glands. In cicatricial tissue, changes which appear to indicate 



236 SURGICAL PATHOLOGY. 

preceding stages to amyloid formation may be seen. Instead of a per- 
fectly definite color-reaction with gentian-violet, there may be only a 
slight reddish or mahogany tint given to the tissues. The corpora 
amylacea are composed of a substance either amyloid itself or closely 
related to it. These are small, firm, round bodies which vary consider- 
ably in size, are formed normally in the prostate gland, and have a con- 
centric structure which gives them a striking similarity to starch-granules. 
They have nothing to do with the general amyloid disease, and are formed 
in consequence of local conditions in the tissues. In the prostate they 
appear to be due to accumulation of degenerated epithelium. 

Calcification. 

Lime-salts may be deposited within the tissues in the form of a gene- 
ral infiltration which is spoken of as calcification, or in the form of 
masses not connected with the tissues and which are called concrements, 
stones, or calculi. Calcification never takes place in perfectly normal 
tissues, but the deposit of the lime-salts is always preceded by necrosis. 
It is probable that the necrotic tissue undergoes certain modifications in 
its chemical reaction, in consequence of which the lime-salts held in sus- 
pension in the fluids of the tissue are deposited in it. Calcification is 
especially apt to take place in dense cicatricial connective tissue which is 
poor in cells and nuclei. It is also frequently seen in the degenerated 
tissue in the walls of the blood-vessels, in tumors, and, in fact, every- 
where where there is necrotic tissue. The infiltration may be found 
only in the intercellular substance, the cells having disappeared, or in 
some cases it is found in the cells themselves, the intercellular substance 
being little or not at all affected. One of the most frequent places in 
which the lime-salts are deposited is in the walls of the large arteries 
and in the left side of the heart. It would appear, at first sight, as 
though there might be some connection between the lime-salts and 
arterial blood, but the truth is that the various forms of degeneration of 
the blood-vessels and the endocardium are more common in the left side 
of the heart and in the arteries than in the right side of the heart and 
in the veins. Thrombi may become calcified, forming vein-stones or 
phleboliths, and the necrotic tissue of an infarction may also become 
completely calcified. In general, calcification takes place in the lower 
animals, especially in the herbivora, to a much greater extent than in 
man. In gout there is a deposit of the urate of soda in the tissues. This 
may take place in the kidneys, in the skin, in the subcutaneous tissues, 
in the tendons, the ligaments, the synovial membranes, and the cartilage 
of the joints. The favorite seat of the deposit is in the metatarso-phalan- 
geal joint of the great toe. It is probable that the deposit takes place 
principally, if not exclusively, in tissues which have undergone necrosis. 
It appears in the form of long, slender, needle-shaped crystals. A forma- 
tion of free concrements or calculi can take place in the various canals 
and cavities of the body which are lined with epithelium. Such concre- 
tions may form in the intestinal canal, in the ducts of the large intestinal 
glands, in the gall-bladder, in the urinary tract, and in the respiratory 
passages. All of these concrements have an organic basis, and lime-salts 
are deposited in this material. In the intestinal glands the calculi consist 



DEATH; NECROSIS; ATROPHY; DEGENERATION. 237 

of a deposit of lime-salts around thickened faeces or various undigested 
vegetable masses. The most frequent place for the formation of con- 
crements is in the gall-bladder, which may contain but one or may be 
filled up with large numbers of them. When there are several present 
their surfaces become faceted by mutual pressure. 

These gall-stones are usually composed of cholesterin united with 
various constituents of the bile. In rarer cases they are formed from 
carbonate of lime. After the cholesterin is dissolved there still remains 
a homogeneous substance. There can be no doubt that the formation of 
gall-stones is due to the incrustation of an organic mucoid substance 
with the constituents of the bile. Colon bacilli have been found in gall- 
stones. 

The most important concrements and calculi of the body are those 
found in the urinary passages. They may form either in the kidney, in 
the ureter, or in the bladder. In the kidney they not infrequently form 
large irregular masses which may fill up the entire pelvis of the kidney 
and extend into the calyces, or only small masses may be formed. Con- 
crements appear in the tissue of the kidney itself in the form of very 
small masses, which may either lie in necrotic epithelium or in the 
lumen of the tubules. In the so-called uric-acid infarction of the kid- 
ney, which is so common in children who die in the first week of life, 
there is simply a deposit of urinary sediment in the occluded tubules. 
The large calculi formed in the urinary bladder consist of an organic 
substance, probably related to albumin, in which various salts are de- 
posited. What sort of material will be deposited in these masses depends 
upon circumstances. If large amounts of uric acid are excreted, as in 
the uric-acid diathesis, calculi may form composed of this. When there 
is decomposition of the urine in the bladder, with the production of 
triple phosphates, calculi can be formed of this substance. When a cal- 
culus has once been formed the irritation which it produces is favorable 
to its increase. All sorts of foreign bodies introduced into the bladder 
can serve as nuclei for the formation of calculi. 

Pigmentation. 

Many of the normal tissues of the body, both connective tissue and 
epithelium, contain a certain amount of pigment. The pigment is 
almost always contained in the cells, and consists of brown or dark 
amorphous granules. Examples of such pigmentation are found in 
the hair and in the choroid of the eye. The nerve-cells in the central 
nervous system contain a small amount of pigment, and pigment is also 
contained in the cells of some of the glands. The skin may show a 
general pigmentation, or the pigment is seen only at certain places ; for 
instance, in the axilla and over the scrotum. During pregnancy the 
pigment of the skin, especially in brunettes, undergoes a considerable 
increase. There may be a marked increase in the pigment brought about 
by certain diseases, as in Addison's disease, in which lesions may be found 
in the suprarenal capsules or in the semilunar ganglia. The pigment of 
the heart shows considerable increase in certain forms of atrophy of the 
myocardium, especially in the atrophy of old age. Pathological pigmen- 
tation is also seen in the freckles of the skin and in the congenital pig- 



238 SUBGICAL PATHOLOGY. 

mented moles. Certain tumors belonging to the sarcomas also show a 
marked degree of pigmentation. The pigment may be brown or show 
every degree of transition up to perfectly black masses. It usually lies 
in the cells, and rarely in the intercellular substance. When it is found 
in the intercellular substance, it is probably due to its being set free by 
rupture and destruction of cells. The formation of pigment seems to be, 
in the main, a property of cells belonging to the connective tissue. In 
the skin, although the pigment may be contained in or between the 
epithelial cells, it appears to be formed in large branched cells in the 
subcutaneous tissue. The source of the pigment has not been in all cases 
definitely ascertained. It is true that pigment may be formed from the 
blood-coloring matter, but hemorrhage is not generally found in the areas 
where pigmentation is taking place. The pigment which is derived 
from the blood under ordinary conditions is usually brown or reddish- 
brown, and has not the deep-brown or black color found in other con- 
ditions. Chemical investigation has shown that some of the pigment 
contains iron, while other pigment is free from it. The blood-extrava- 
sation which takes place in an ordinary bruise undergoes various changes 
of color. When the extravasation has taken place in a transparent 
tissue — for instance, in the pleura or in the peritoneum — a rusty-brown 
color may remain for a long time afterward. All these changes in color 
correspond to physical and chemical alterations of the haemoglobin and 
the iron contained in this. When hemorrhage takes place in the tissues, 
the red blood-corpuscles may be taken up by the lymphatics in an un- 
changed condition, or the hsemoglobin may be dissolved out of them and 
taken up by the circulation. It is this dissolved blood-coloring matter 
which produces the various changes of color in the neighborhood of blood- 
extravasations. Blood-crystals may be formed from the extravasated 
blood, and they are frequently found in the remains of old hemorrhages. 
In cases of chronic passive congestion there is usually a certain amount 
of diapedesis, and a brownish color may be given the tissues by the 
presence of the blood-pigment. The best example of this is seen in the 
chronic passive congestion of the lung, the salmon-brown color in this 
being due to the presence of large cells in the alveoli of the lung, which 
are filled with brownish-red or brownish-yellow pigment. In jaundice or 
icterus the pigmentation is due to the coloring material of the bile. 
During life this is easily recognized in the skin and in the conjunctiva. 
When the jaundice first appears the tissues have a bright-yellow color, 
and after it has existed for some time this changes into an olive-green 
or a grayish-green color. Jaundice is usually due to some condition 
which interferes with the passage of the bile and leads to its absorption 
into the lymphatics of the Hver, and from this into the blood. Swelling 
of the mucous membrane of the bile-ducts, due to catarrhal inflam- 
mation, narrowing or closure of the bile-ducts by cicatrices or by the 
presence of gall-stones, tumors developed in the bile-duct, or the pressure 
of tumors outside of the ducts, may all be followed by jaundice. The com- 
mon bile-duct is comparatively large and thin-walled. The pressure of 
the bile within it is very low, and a very slight degree of distention will 
lead to the retention of the bile and its absorption. According to various 
authors, there is a form of jaundice, the so-called hsematogenous jaundice, 
which is produced by the conversion of the hsemoglobin of the blood in 



TUBERCULOSIS AND TUBERCLE. 239 

the blood-vessels into bile-coloring matter. The results of experiments 
have tended to show that a pure hsematogenous jaundice does not exist, 
but there may be a destruction of red blood-corpuscles in the blood, and 
the hsematoidin thus set free is converted in the liver into bilirubin and 
then absorbed. 

The tissues may also become pigmented from pigment which is taken 
into the body from without and absorbed in the tissues. The pigment 
may enter the body by means of the respiratory or intestinal tract and 
from wounds. In the operation of tattooing the skin is broken and in- 
soluble coloring material is rubbed into the wounded surface. A portion 
of this material remains in the tissues at the place, and a portion is taken 
up by the lymphatics and carried to the adjacent lymphatic glands. In 
case the arm is tattooed the epitrochlear and the axillary glands always 
contain the same pigment which is rubbed into the skin. The lungs may 
undergo a marked pigmentation in consequence of the inspiration of dust 
and particles of carbon. A part of the dust remains in the lungs, and is 
found both in the walls of the alveoli and in the thickened and indurated 
tissue which results from the chronic inflammation set up by the presence 
of the foreign particles. A part of the material is carried to the nearest 
lymph-glands and produces pigmentation of these. 

An interesting form of pigmentation is due to the introduction of 
silver salts into the body. When nitrate of silver has been used 
medicinally for some time, the skin acquires a grayish-brown appear- 
ance and the organs may also become pigmented. The silver is deposited 
in the form of fine granules in the tissues of the organs. 

In malaria there is a formation of pigment in the blood. This condi- 
tion is found in all forms of malaria, and is due to the destruction of the 
red corpuscles by the malarial parasites which inhabit them. The pig- 
ment which is formed is derived from the hsemoglobin. It is found both 
in the red and white corpuscles. In the red corpuscles it is found in the 
parasites which they enclose. In the white corpuscles the pigment is 
also derived from the parasites, the pigment produced by them in the 
red corpuscles being taken up by the white corpuscles. In certain 
stages of the disease pigmented parasites may also be found free in the 
blood. The pigment is also deposited in certain organs of the body, 
notably in the spleen and in the liver. 



VI. TUBERCULOSIS AND TUBERCLE. 

TuBBECULOSis is an infectious disease produced by the tubercle 
bacillus. It is characterized by the formation of larger and smaller 
circumscribed nodules called tubercles, by more diffuse formation of 
tissue of the same character as that composing the nodules, and by 
various forms of inflammation. The word "tubercle" was first used 
without any specific meaning to describe a small nodule. In 1796, 
Baillie, the nephew of John Hunter, gave the first description of 
tubercle as found in the lungs. It was noticed that these tubercles 
were frequently found associated with a destructive disease of the lungs, 
and finally both the tubercles and the destruction of lung-tissue accom- 



240 SURGICAL PATHOLOGY. 

panying their presence were referred to one and the same cause. After- 
ward nodules of a similar character were found in the lymph-glands, in 
the tissues of diseased joints, and in various other places in the body. 
It was found that wherever these nodules appeared they were composed 
essentially of the same sort of tissue, and that they were particularly 
prone to a form of degeneration by which they became changed into a 
substance resembling certain sorts of cheese. Tissue of the same general 
character as the tubercles was also found, not in circumscribed masses, 
but rather diffusely, and it was found that this tissue also underwent 
caseation. When inflammation accompanied the process the products also 
became caseous. There is no doubt that although the form of degen- 
eration called caseation is not a specific process limited to the tuberculous 
tissue, it so commonly takes place in this that it has served more than 
any other morphological factor to unite under one head the various 
manifestations of the disease. The conception of tuberculosis as an 
infectious disease was founded on the anatomical study of the disease 
and its mode of progression before the discovery of the specific organ- 
ism. Even twenty years before the discovery of the bacillus it was 
found that a disease agreeing in all essential respects with the disease as 
found in man could be induced in rabbits by inoculating them with the 
products of the disease from man. 

It is now universally acknowledged that a bacillus is the cause of the 
disease. This was demonstrated by Koch in 1881, and all the work 
which has since been done has served to confirm the work of Koch. 
The bacillus tuberculosis is one of the smallest of micro-organisms. It 
is from one-quarter to one-half the diameter of a red blood-corpuscle in 
length, and the length is usually five or six times the breadth. The 
bacilli are usually somewhat bent and the ends are rounded. Special 
methods of staining are necessary to demonstrate them. A great many 
methods have been given, but they all consist in the use of fluids 
which stain intensely, followed by decolorizing solutions which remove 
the color from everything but the bacilli. When stained the bacilli may 
be of a homogeneous color, or they may show an alternation of intensely 
stained particles and clear spaces. These clear spaces were first sup- 
posed to represent spores, but it is doubtful whether they should be so 
considered. It is probable that there is no growth of the organisms 
outside of the body under oi^'dinary circumstances. Special media and 
an elevated temperature are necessary for their growth, which is very 
slow, there being usually no indication of it for several weeks. There 
is a great difference in the susceptibility of different animals to the dis- 
ease. Guinea-pigs are among the most susceptible, and these succumb 
in from six weeks to three months after inoculation. 

For a long time no typical structure was regarded as characteristic 
of tubercle. Virchow described the tubercle as a nodule composed 
of small round cells similar to those found in granulation tissue, and 
derived from multiplication of the connective-tissue cells, and called 
attention to the tendency of the cells in the centre of the nodule to 
undergo necrosis. As the methods of histological investigation improved 
tubercle was studied more closely, and it was found to have a more 
or less typical structure. Langhaus gave a more detailed description 
of certain large multinucleated cells commonly found in tubercle; a 



TUBERCULOSIS AND TUBERCLE. 241 

peculiar reticulum between the cells was described by other observers. 
When a very young miliary tubercle is examined after suitable methods 
of hardening, a reticulum is seen, in the meshes of which the cells lie. 
The extent to which the reticulum is developed depends upon the age 
of the tubercle and the character of the tissue in M^hich it develops. It 
may be as firm and definite as the reticulum of a lymphatic gland, and 
in other cases scarcely a trace of it may be seen. There ai-e various sorts 
of cells in the nodule, the most prominent of which from their number 
are the epithelioid cells. These are cells somewhat resembling epithelial 
cells ; they have a pale, finely-granular or homogeneous protoplasm and 
large oval vesicular nuclei. The arrangement of these cells with refer- 
ence to the reticulum varies. Sometimes they appear to lie in the meshes 
of a more or less fibrous reticulum ; sometimes they form the reticulum. 
The cell-outlines are never clear and distinct ; the cells are usually fused 
together. The epithelioid cells are also found, not as distinct groups, 
but more or less scattered in the tissue. Among the epithelioid cells, 
lying between them or in the meshes formed by their union, are round 
cells similar to those found in young granulation tissue. These cells 
vary in number, and are most abundant in the periphery of the nodule. 
The large, multinucleated giant-cells are a prominent feature of the 
tubercle. Sometimes one of them forms the centre of the nodule, and 
has long processes which communicate with the reticulum ; or they may 
be perfectly round, without processes, and lie in a space surrounded by 
epithelioid cells. In some cases they are situated in the periphery of 
the nodule. The nuclei of the giant-cells are either arranged around 
the periphery, with their long axis perpendicular to the centre, or they 
are grouped in masses at either end of an elongated cell. The histogenesis 
of the tubercle has been carefully studied, but we are still far from com- 
pletely understanding it. Baumgarten considers the epithelioid cells as 
the most important cells found, and that they are derived from the pre- 
existent cells of the tissue under the influence of the tubercle bacilli. 
They may be formed from the epithelial cells of glands, from the con- 
nective-tissue cells, or from the cells of the blood-vessels. According to 
Baumgarten, the first step in the formation of a tubercle is the presence 
of tubercle bacilli in the tissue. These enter into the fixed cells, no 
matter what the character of these may be, and produce cellular pro- 
liferation, the newly-formed cells being the epithelioid cells. The pro- 
duction of the giant-cells is a more obscure process. AYeigert thinks 
that they are produced by the proliferation of degenerated cells, the 
nucleus dividing without separation of the protoplasm. In some cases 
they appear to be produced by fusion of the epithelioid cells, and they 
are undoubtedly sometimes formed in blood-vessels, and may be traced 
in continuity with vessels. They are probably formed in a variety of 
ways. The small round cells, found in varying numbers in the tubercle, 
are derived, like the granulation-cells, from multiplication of the con- 
nective-tissue cells in the tissue in which the tubercle is formed. Little 
is known of the formation of the reticulum. It is probably in. large part 
composed of the remains of the connective-tissue fibres which have been 
pressed apart by the proliferating cells. It may be in part newly formed 
by the cells of the tubercle, which for the most part are derived from the 
connective tissue and under ordinary circumstances would form such tissue. 

Vol. I.— 16 



242 SURGICAL PATHOLOGY. 

The tubercle is a non-vascular structure. The blood-vessels which 
are present in the tissue where the tubercle develops become occluded by 
thrombosis or from the pressure of the numbers of cells, and no new 
blood-vessels make their way into it. 

This description of tubercle applies to very young nodules in which 
no degeneration has taken place. The first evidence of such degen- 
eration is shown in hardened specimens by the nuclei of the cells in 
the interior staining less brilliantly. In sections of fresh tissue more 
or less extensive fatty degeneration of the cells in the centre is found. 
The nuclei cease to stain, and the cells fuse together in a solid homo- 
geneous mass in which no cell-outlines can be seen. The form of degen- 
eration is that described by Weigert as coagulation-necrosis, and it is 
always preceded by fatty degeneration. A zone of closely-packed fat- 
molecules is always found around the necrotic centre. In the giant-cells 
the same process seems to take place. The centre is similar to the necrotic 
centre of the tubercle, and around this, just inside the nuclei, there is a 
zone of closely-packed fat-granules. 

Macroscoj)ically, the tubercle when very young is pale, transparent, 
and with difficulty distinguished in the tissue. When degeneration 
begins it is white, opaque, and easily seen. The white color is not due 
to the absence of vessels alone, but rather to the presence of the fat- 
molecules. 

With the appearance of degeneration in the tubercle another cellular 
element enters into it. This is the polynuclear leucocyte. Necrotic tissue, 
however caused, exerts a positive attraction on the leucocytes, and the 
necrotic tissue in the tubercle has the same power. The polynuclear 
leucocytes may be recognized by their irregularity in form and by the 
brightness with which they stain. They enter into the tubercle and into 
the necrotic tissue, often forming a definite ring around the latter. In 
the degenerated area they seem to undergo the same fate as the other 
cells. The nuclei break up into fragments and form the small, brightly- 
staining granules seen in the tissue. Occasionally they may be found 
within the giant-cells. 

The fatty degeneration and caseation to which the tubercle is so 
prone has been attributed principally to the absence of blood-vessels. 
Although this may play a part, the degeneration of the tissue cannot be 
attributed solely to this cause. We find other structures in the body, of 
the same size as, or even larger than, the tubercle, in which there are no 
vessels and which do not show the same tendency to degeneration. The 
necrosis of the cells is due more to the influence of the bacilli or their 
chemical products on the tissue than to the absence of blood-vessels. 

The relation of the tubercle to the surrounding tissue differs. In 
most cases there is around it a well-marked zone of granulation tissue 
filled with round cells which become more abundant in the periphery of 
the tubercle, and finally merge into the surrounding granulation tissue 
Avithout a sharp line of demarcation. As the tubercle increases in size the 
central caseation increases in extent and the granulation tissue changes 
into that of the tubercle, the round cells becoming epithelioid in character. 

The tubercle may undergo other forms of degeneration than the case- 
ous. The entire mass may become converted into a perfectly smooth 
hyaline substance, or, before necrosis takes place, connective tissue may 



TUBERCULOSIS AND TUBERCLE. 243 

be formed from the cells, and such tubercles, even after caseation, are 
much firmer and harder than those in which the necrotic tissue is com- 
posed of cells alone. 

The number of tubercle bacilli in the tissue varies; they may be 
■present in large numbers or may be absent altogether. As a general 
rule, they are not so numerous in the youngest tubercles as tliey are in 
those in which degeneration is well advanced. In certain places they 
seem to be absent as a rule. In acute miliary tuberculosis of the liver 
I have frequently not been able to find a single bacillus in any of the 
numerous tubercles in the tissue. It is probable that under certain con- 
ditions they are destroyed by the tissue, or they may become so changed 
as to be no longer recognizable. The bacilli occupy no constant position 
in the tissue ; they may be found within or lying between the epithelioid 
cells. Sometimes a mass of them may be seen in the centre of the case-, 
ons mass, or the giant-cells may contain them in varying numbers. 

The miliary tubercles may appear alone, or in numbers forming the 
large conglomerate tubercles. Most of the tubercles which are visible 
to the naked eye are composed of several nodules united together. 
These larger conglomerate nodules are formed around a single tubercle > 
which seems to serve as a focus of infection. The tubercle bacilli from 
this are carried, either by the lymph-stream or enclosed in wandering 
cells, into the surrounding tissue, in which numbers of tubercles are thus 
developed. As the caseation in the individual tubercles advances it affects 
also the tissue lying between them, so that finally a large caseous area 
is formed which is surrounded by a zone of miliary tubercles. The 
large solitary tubercles which are frequently found in the brain, and less 
frequently in the liver and other parts of the body, are formed in this 
way. Although the miliary tubercle is the most characteristic of the 
lesions produced by the tubercle bacillus, it forms but a small part of 
the lesions of the disease. The formation of a tissue similar to that of 
the miliary tubercle, and which, appears not as a nodule, but as a diffuse 
infiltration of the tissue, is a much more prominent part of the process. 
The formation of this tissue is closely related to inflammation. Where 
in an ordinary inflammation there would be a formation of granulation 
tissue, under the influence of the tubercle bacillus a tissue composed of 
epithelioid and giant^cells, and which is peculiarly prone to necrosis and 
caseation, is produced. In tuberculosis of the joints the pale masses of 
granulation tissue around the joints show on the outside a narrow rim 
of caseation, and back of this a tissue composed largely of epithelioid 
and giant-cells. In this tissue there are frequently circumscribed 
tubercles. 

Not only is the tubercle in its formation closely related to inflamma- 
tory new formations of tissue, but it is always accompanied by inflam- 
mation. The nodular tubercle as a foreign body excites inflammation 
around it. The zone of granulation tissue around a tubercle is the 
result of a reactive inflammation of the tissue. The chemical sub- 
stances which are produced by the bacilli and in the tuberculous tissue 
may exert a non-specific but simplj- injurious action on the surrounding 
tissue, which will be followed by inflammation. The bacilli themselves, 
instead of causing the more typical tissue-formations, may excite inflam- 
mation. The fornl of inflammation varies. In some cases an exuda- 



244 SURGICAL PATHOLOGY. 

tion containing fibrin in varying amounts may be produced ; in other 
cases a typical suppuration. In no other tissue in the body is this inti- 
mate association with inflammation so evident as in the lungs. Apart 
from the presence of miliary tubercles, which ordinarily play but a 
small part in the process, the lesions of pulmonary tuberculosis are 
chiefly inflammatory. The greater part of the lesions is due to tuber- 
culous pneumonia, in which there is consolidation of the lungs, due to 
exudation and accumulation of cells in the alveoli. The exudation in 
some cases contains much fibrin ; in others it may be chiefly serous, or 
the alveoli may be filled with a hyaline gelatinous substance. The cells 
within the alveoli are chiefly large, pale, epithelioid cells, mingled with 
both white and red corpuscles. In some cases, especially on serous sur- 
faces, the exudation is chiefly hemorrhagic. Always, particularly in the 
lungs, along with the inflammatory processes due directly to the action 
of the tubercle bacilli and their soluble chemical products, there are 
inflammatory lesions due to conditions which the bacilli create. 

The inflammatory tissue produced in the lungs by the bacilli under- 
goes the same caseation as the tubercle. It becomes converted into a 
dry, homogeneous, necrotic mass. The fibrin becomes enclosed in it, and 
may still be recognized in the caseous tissue by appropriate methods of 
sta,ining. On microscopic examination of the brittle caseous mass the 
anatomical structure of the tissue composing it may still be recognized. 
In the lung the walls of the alveoli appear, dividing the caseous tissue 
into small areas. The caseation follows the same course as in the 
tubercle, commencing in the centre and gradually extending to the 
periphery. An entire lobe, or even an entire lung, may be converted 
into a solid, necrotic mass pf tissue. 

The caseous tissue does not tend to remain, but after a variable length 
of time it undergoes softening. The cause of this is not fully understood. 
The dry, caseous tissue becomes converted into a soft, fluid, puriform 
mass. On microscopic examination fragments and detritus of tissue and 
cells may be recognized, with here and there a few^ well-presers'ed leuco- 
cytes. The cause of the softening may be due to changes taking place 
in the tissue spontaneously or to the action of influences from without. 
The necrotic tissue forms a favorable, seat for the action of other micro- 
organisms which can gain access to it by the bronchi. The softening 
may be distinctly purulent ; there may be a purulent inflammation in the 
tissue around it, and the caseous matter may be dissolved in the purulent 
exudation. As soon as softening takes place favorable conditions for 
further infection are produced. Not only are the tubercle bacilli present 
in the softened material, but there are other organisms. It is probable 
that even without the presence of organisms the chemical products pres- 
ent may exert a deleterious influence on the tissues. Bronchi always 
open into the softened area, and offer a direct route for infection of other 
parts of the lungs. To the specific action of the various substances in 
the softened tissues must be added the effects which may be produced by 
the mechanical action of solid particles occluding the small bronchi. It 
is easy to see why in such a tissue as that of the lungs tuberculosis should 
produce such a variety of lesions. 

There is probably no disease in which there is such a varietv in the 
lesions as is found in tuberculosis. A careful study of the lung-lesions 



TUBERCULOSIS AXD TUBERCLE. 245 

in a case of chronic tuberculosis would show nearly all the pathological 
processes. The course of the disease also varies. In some cases it may 
advance rapidly and lead to death in a few months or even weeks ; in 
other cases it pursues the most protracted course, may continue during 
the entire life of the individual, and in the end only indirectly contribute 
to death. All of these differences in the effects of infection with the 
bacillus depend upon a number of factors. 

All individuals are not equally susceptible to the disease. It was 
formerly generally believed that the disease itself was inherited, but it is 
more probable that not the disease itself, but a greater or less suscep- 
tibility to the disease, is inherited. Other things being equal, children 
of tuberculous parents, especially if the disease has been in the family for 
a number of generations, are more liable to be affected with tuberculosis 
than the children of parents who were free from this disease. This 
special susceptibility or tendency may not be expressed in any other 
weakness or habit of the body : such children, born of parents in good 
circumstances of life, may develop strong and robust bodies with more 
than the average powers of endurance. One factor must always be 
considered — namely, that in general these children have greater oppor- 
tunities for infection if they are living in the house with tuberculous 
people. It is also probable that certain races show a greater susceptibility 
than others to this disease. In this country certainly the colored and 
the Celtic races seem to be more liable to the disease than any other, 
while the Jewish race appears to possess a certain degree of immunity 
against it. The same thing is true of cattle. The cattle coming from 
the Channel Islands, the Alderney and Jersey stock, especially the pure 
breeds, have much more of the disease among them than any other 
breeds. 

It is probable that there are also differences in the virulence of the 
bacilli in different cases. Even inoculations on guinea-pigs of the same 
age with the same amounts of virus from different sources show differ- 
ences in the course of the disease. 

The course of the disease will further be influenced by the manner in 
wliich the organisms gain entrance into the tissue. They may enter 
it by means of canals or ducts which communicate with the outside, 
or by the blood- and lymphatic vessels. In this way either tuberculous 
inflammations or miliary tubercles may be produced. It is probably 
not necessary to have an actual lesion of continuity for the bacilli to 
pass into the tissue. It has been shown that the disease can be produced 
by rubbing the organisms on the skin of a rabbit. Tuberculosis of the 
alimentary canal in man probably takes place without any preceding 
lesion. The tubercles here appear first in the lymph-glandular tissue of 
the gut, and no lesion of the mucous surface may be visible. Not only 
is there a general difference in the susceptibility of the tissue of different 
individuals, but there are differences in the different tissues of the same 
individual. Some tissues are almost exempt. In certain cases tubercle 
bacilli may be found in great quantities in the blood, and miliary tuber- 
cles be formed all over the body, except in the muscles. The ovary 
shows a relative immunity, and the pancreas and thyroid are rather 
rarely attacked. It cannot be that these organs are protected from the 
entrance of the bacilli, for in cases of infection by the blood they are 



246 SURGICAL PATHOLOGY. 

equally liable to have the bacilli carried into them. None of the tissues 
enjoy "an absolute immunity. Even the muscles may be invaded by the 
gradual extension of tuberculous foci into them. In a tuberculous ulcer 
of the tongue tubercles are found in the muscular tissue for quite a long 
distance beneath the ulcer. In cases of joint tuberculosis also the adjacent 
muscles may be involved by the extension of the disease. 

There is always some primary focus of the disease in the body. The 
primary seat of the disease in most cases is in the lungs, but it may com- 
mence in almost any other organ of the body; From the primary focus 
the infection extends, following various routes. There may be infection 
of the tissues in direct continuity. The bacilli may be carried enclosed 
in cells, or they may extend' by growth into the tissue adjoining, and in this 
way large tuberculous nodules may be formed. The bacilli may pass 
along the lymphatics, either into the surrounding tissue or into the 
lymphatic glands into which the lymph-vessels empty. The infection 
of the lymphatic glands almost surely takes place, and in many cases 
they may present the only evidence of the disease. In tuberculosis of 
the lungs the bronchial glands are always aifected : if the intestine be 
affected, the mesentery glands are tuberculous. In many cases the 
bacilli are probably carried directly to the lymph-glands from the seat 
of entry without producing any lesions where they have entered. It is 
probable that in many cases the bacilli gain entrance into the tissues 
through the mucous membrane of the mouth or pharynx, and the first 
evidence of the disease is in the cervical glands. The glands appear to 
protect the organism from further infection for some time. The tissue 
of the lymphatic glands offers a suitable locality for the growth of the 
bacilli. Extensive lesions are produced in them, and finally the glands 
serve as foci for further infection. The glands next in order become 
affected, and in this way all the lymphatics and lymph-glands up to the 
thoracic duct may gradually become tuberculous ; and finally the bacilli 
are carried directly into the blood. In most cases the infection follows 
in the direction of the lymph-current, but it may also proceed against 
the stream. 

Infection may also take place by the bacilli being carried along 
open canals or ducts from one part of an organ to another or to various 
parts of the body. The lungs offer the most suitable Conditions for this 
mode of infection. The primary seat of the disease in most cases is in 
the '• apices, and when softening of the caseous tissue takes place the 
detritus, full of bacilli, may be carried by aspiration into every other 
part of the lungs. The bacilli are contained in the sputum, and further 
infection both of the air-passages and of the alimentary canal takes place 
from this. 

This mode of infection is seen also in the genito-urinary tuberculosis 
in the male. Here, in the majority of cases, the primary seat of the dis- 
ease is in the epididymis. It may be confined to this, or the testicle may 
be affected by continuity. The epididymis is converted into a more or 
less firm, caseous mass. From this the disease extends along the vas 
deferens, which becomes enlarged, and on section the interior is found to 
be lined with a whitish caseous tissue. In both the vas deferens and epi- 
didymis the seat of the disease is primarily in the epithelium and takes the 
form of a tuberculous inflammation. The seminal vesicles on the same side 



TUBERCULOSIS AXD TUBERCLE. 247 

become affected in most cases, or they may be passed by and the disease 
appear in the prostate or bladder. Up to this point it is easy to see how 
the infection has taken place : the extension has been in the direction of 
the secretion, and the bacilli could be carried along with the secretion. 
From the bladder the extension is in a direction opposite to the flow of 
the secretion. With or without any involvement of the ureter infection 
of the pelvis of the kidney and of the adjoining kidney-tissue takes place. 
It is probable that the bacilli find suitable conditions for growth in the 
ureter, and grow along the walls, just as on the surface of a solid medium, 
until the pelvis of the kidney is reached. There is no other way for 
infection to take place from the bladder to the kidney than along the 
ureter. There is no lymphatic or vascular connection. The proof that 
this is the usual route of infection in genito-urinary tuberculosis is shown 
by the certainty witli which the disease can be traced step by step, and 
the extreme rarity flf the disease in females as compared with males. 
In some cases the disease appears to be primary in the kidney, and the 
infection may take place in the opposite direction. 

The blood plays an important part in the extension. Sometimes the 
bacilli gain entrance into the blood from the lymphatics. The more com- 
mon way is by a direct infection of the blood. Tuberculosis of some of 
the large veins of the body may take place, the vein being affected by the 
extension of a tuberculous process in an adjoining tissue. The bacilli are 
carried by the blood into all the organs of the body, and a general miliary 
tuberculosis is the result. Even in this some of the tissues are exempt. 
Miliary tul)ercles are never found in the muscles or in the skin, and 
only rarely in the alimentary canal or in the ovaries. Infection by 
the blood may take place without the production of a general miliary 
tuberculosis. In almost every case of extensive tuberculosis a few 
tubercle bacilli probably enter into the blood. These will be deposited 
chiefly in those organs in which the conditions of the circulation are 
most favorable for the retention of fine solid particles. The liver offers 
the most suitable conditions for this, and in every case careful search 
will show the presence of a few tubercles in this organ. In some cases 
the bacilli may apparently gain access to the blood without producing 
any other lesions. From the primary infection they may in some way 
gain entrance into the blood and be deposited in various organs. In no 
other way are we able to explain the primary tuberculosis of the bones 
and other organs into which they could have been carried only by the 
blood. 

Of late the theory of congenital tuberculosis, the result of intra- 
uterine infection, has received more credence than formerly. Baum- 
garten particularly upholds this view, and explains in this way certain 
cases in which the infection is otherwise obscure. In a few cases con- 
genital tuberculosis has been proven beyond doubt both in animals and 
in man. The first case in which this was shown was in the organs of a 
fcetal calf, and careful investigation has shown that this condition is not so 
very uncommon. Baumgarten found a caseous tuberculous nodule in the 
cervical vertebi'se of a stillborn infant. Birch-Hirschfeld found tubercle 
bacilli in a seven months' fcetus and placenta removed by Csesarean section 
from a mother affected with general miliary tuberculosis. The bacilli 
were demonstrated both by direct examination and by the inoculation of 



248 SURGICAL PATHOLOGY. 

guinea-pigs. Cases of tuberculosis in infants dying the first few days 
or weeks after birth are not so very uncommon, and many of these cases 
should be regarded as due to intra-uterine infection. Gartner has found 
that transmission of tubercle bacilli from the mother to the foetus is not 
very uncommon in mice, canary birds, and rabbits. Nor is the infre- 
quency of tuberculosis in new-born children and infants a conclusive 
argument against intra-uterine infection. The infection may take 
place in intra-uterine life, and the disease remain latent for a number 
of years. 

The question as to the frequency of directly inherited or congenital 
tuberculosis must be considered in connection with the fact, referred to 
above (p. 245), that the children of a tuberculous parent usually live in 
a house or room which is more or less infected with the specific bacilli 
derived from the sputa of the parent, and hence are more than usually 
liable to contract the disease. 



GENERAL BACTERIOLOGY OF SURGICAL 
INFECTIONS. 

By WILLIAM H. WELCH, M. D. 



Members of each of the three groups of pathogenic micro-organisms 
— bacteria, fungi, and protozoa — may cause surgical infections. Fungi 
and protozoa, however, are far less commonly concerned in these infec- 
tions than are bacteria. In a general consideration of the conditions of 
surgical infection bacteria are the organisms which require chief atten- 
tion, so that the subjects to be considered in this article can be appro- 
priately included under the designation " General Bacteriology of Surgi- 
cal Infections." 

The term " general bacteriology " is here used in distinction from 
" special bacteriology " to designate the general relations of bacteria to 
surgical infections. It is not deemed necessary in this article to enter 
into a detailed consideration of the morphological and cultural charac- 
ters of bacteria. This subject is fully treated in works especially devoted 
to bacteriology. 

Infectious diseases which require especial coiisideration by the sur- 
geon include, on the one hand, many specific infections, such as tubercu- 
losis, tetanus, glanders, anthrax, and actinomycosis, and, on the other 
hand, traumatic and other inflammatory and septic infections caused by 
various widely-distributed bacterial species. 

The specific infectious diseases, such as tuberculosis, tetanus, etc., are 
for the most part sharply differentiated by their anatomical and clinical 
characters, and are caused by micro-organisms which are constantly and 
exclusively associated with their respective diseases. 

On the other hand, the common traumatic infections and other sur- 
gical inflammations and septic processes do not present equally sharp and 
definite differential characters, and apparently identical or similar patho- 
logical processes belonging to this group. of affections may be caused by 
various micro-organisms. Thus we do not find in such diseases as septi- 
caemia, pyaemia, abscesses, osteomyelitis, puerperal fever, or other septic 
and localized inflammations, or, in general, in the infections of wounds, 
any single bacterial species constantly and exclusively associated with 
each of these affections, but each disease of this group may be caused 
by more than one species of micro-organism. 

The etiolog'y of these common septic and inflammaitory affections 
presents for our consideration many problems quite distinct from those 
pertaining to the causation of the specific infections. The views n,ow held 
as regards sources of infection, operative procedures, and the manage- 
ment of wounds have been developed largely as the result of investiga- 
tions concerning the relation of bacteria to traumatic infections. 

249 



250 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

It is important that the surgeon should become familiar with the 
various kinds of bacteria concerned in surgical infections, with their 
distribution on exposed surfaces of the body and in the outer world, 
with the ways by which they may enter and be discharged from the 
body, with the various conditions which favor their invasion and multi- 
plication in the body, with their pathogenic manifestations, and with 
the means of combating them. It is proposed in this article to 
present the more important considerations pertaining to these sub- 
jects so far as they do not fall more appropriately for their treatment 
to other sections of this work. 

We shall consider first the distribution of bacteria on exposed sur- 
faces of the body, having especially in view its surgical bearings. 
Knowledge of the distribution of pathogenic bacteria is of importance 
in the study of the causation of surgical infections, as indeed of all 
infectious diseases. 

Bacteria op the Skin. 

There are various questions of surgical interest relating to the bacteria 
of the skin. The destruction of the surface bacteria both on the hands 
of the operator and his assistants and over the field of operation in the 
patient is of fundamental importance in surgical technique. It is 
important to determine the possibilities of danger from infection by 
bacteria commonly or occasionally found in or on the skin. Ignorance 
of the bacterial flora of the normal skin has led some investigators to 
erroneous interpretations of their observations as to the source of bacteria 
found in wounds treated aseptically or antiseptically, and as to the 
presence of supposed specific pathogenic bacteria in certain cutaneous 
diseases. 

The micro-organisms of the human skin have been studied by several 
investigators, of whom may be mentioned Bizzozero, Bordoni-Uffreduzzi, 
Unna, Maggiora, Mittmann, Fiirbringer, Preindlsberger, Robb and 
Ghriskey, and Welch.' 

As the skin is exposed to contamination from the air and all sorts 
of sources, it is evident that there is scarcely any limit to the number 
of species of bacteria which may possibly be found on the skin. Most 
investigators of this subject have not had the patience or have not thought 
it worth while to attempt to identify or to describe all of the various kinds 
of bacteria developing in cultures from the surface of the skin. Mitt- 
mann mentions seventy-eight diiferent species of cutaneous bacteria, of 
which fifty-six were cocci. His descriptions, however, are so imperfect 
as scarcely to serve for the identification of the species. Preindlsberger 
describes thirty-two species, of which twenty-eight were cocci. Maggiora 
isolated twenty-nine micro-organisms, of which twenty-two wei-e bacteria, 
three budding fungi, and four moulds. Most of these bacteria are such 

' Bizzozero, Virchcm's Archiv, Bd. 98 ; Bordoni-UfFreduzzi, Fortsch-iile der Medicin, 
1886, p. 151 ; Unna, Monatuhefte fur praldkch-.' Dermnlohgie, 1889, 1890, 1891 ; Maggiora, 
Ginrnak della R.Smietd d'lgiene, 1889; Mittmann, Virdiovfs Archiv, Bd. 113; Fiirbringer 
De-iinfekiinn d. Hdnde d. Arztes, Wiesbaden, 1888; Preindlsberger, Ziir Kenntniss der Bac- 
terien den Unlernagelraumes u. s. w.', Wien, 1891 ; Uobb and Ghriskey, Johns Hopkins 
Hospital Bulletin, April, 1892; Welch, Trans, of the Congr. of American Physicians and 
Surgeons, vol. ii., and Maryland Medical Joumcd, Nov. 14, 1891. 



BACTERIA OF THE SKIN. 251 

as are often found in the air or on external objects. Cocci are usually 
found much more abundantly than bacilli in cultures from the skin. 

Great variations exist in different cases as to the kinds and the 
number of bacteria found on the skin. Sometimes one species predomi- 
nates over the rest, indicating that it has multiplied and overgrown other 
bacteria. The conditions in general are not favorable for the growth of 
bacteria on the surface of the skin, but under the nails and in situations 
where moisture collects, as in the axillse, the groins, and between the toes, 
there may be abundant multiplication of certain species of micro- 
organisms. Although bacteria predominate, budding and mould fungi 
are often present. The large number of micro-organisms which accu- 
mulate beneath the nails is a matter of surgical importance. From a 
minute particle of material from this situation sometimes as many as two 
thousand to five thousand colonies develop in culture media, although 
usually the number is much less, and may be very small indeed, perhaps 
not more than three or four colonies. 

The writer in 1891 was the first to call attention to the fact that, 
although in general the bacterial flora of the skin is inconstant and indef- 
inite in its special characters, there is one bacterial species, to -which he 
gave the name of staphylococcus epidermidis albus, which is found with 
such regularity in cultures from the skin that it may properly be regarded 
as a regular inhabitant of the normal skin, just as the bacillus coli com- 
munis is a regular inhabitant of the intestinal canal. The principal data 
relating to this staphylc>coccus were establislied by the researches of Robb 
and Ghriskey. We consider this coccus to be a variety of the staphy- 
lococcus pyogenes albus. It is possessed of feeble pyogenic power, and 
usually liquefies gelatin and coagulates milk more slowly than the ordi- 
nary white pyogenic staphylococcus. For these reasons, but especially 
to emphasize the epidermis as a normal habitat for this organism, we 
applied the designation mentioned. 

One of the chief points of interest relating to this coccus is that it is 
very often, probably regularly, present in layers of epidermis along the 
hair-shafts, deeper than can be reached by any known means of cuta- 
neous disinfection save the application of heat. After complete sterili- 
zation of the surface of the skin, so that scrapings are sterile when 
inoculated into culture media, the pi'esence of this white coccus can still 
be demonstrated by making cultures from sutures passed through the 
skin or from excised pieces of skin. 

The staphylococcus epidermidis albus is usually innocuous. It is found 
frequently in aseptic wounds of the skin without causing suppuration or 
any trouble. The source of this coccus in aseptic wounds does not seem 
to be known to many who have made bacteriological examinations of 
such wounds; thus Btidinger,' who examined in 1892 twenty operative 
wounds which healed by first intention in Billroth's clinic, could not sug- 
gest any other origin for its presence than the air, and C. Fraenkel ^ sug- 
gests that it is brought to the wound by the blood-current — suggestions 
which were rendered quite unnecessary by our previous researches. 

Although this white epidermal staphylococcus is often found in 
wounds without any disturbance in the process of healing, it may be 

^ Biidinger, Wiener klin. Wochenschr., 1892, Nos. 22, 24, 25. 
^ C. Fraenkel, Baumqarten' s Jahresbericht, 1892, p. 28. 



252 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

the cause of some disturbance, characterized especially by elevation of 
temperature and moderate suppuration. This is particularly likely to 
be the case when there is necrotic or strangulated tissue in the wound or 
when foreign bodies have been introduced into the wound. _ It is a com- 
mon, although not the sole, cause of stitch-abscesses, and it is prone to 
travel down along the sides of a drainage-tube, and under these circum- 
stances may cause the wound to suppurate. It is often associated with 
other pyogenic cocci in cutaneous inflammations. We can now under- 
stand how, without any flaw in the antiseptic technique of the surgeon, 
this micro-organism may be present in wounds, and we have a satis- 
factory explanation of the frequent occurrence of stitch-abscesses. 

This white skin-coccus is often present in cultures from blood ob- 
tained by puncture of the human skin and in cultures from the sweat 
after complete disinfection of the surface of the skin. Some _ observers 
seem to have supposed that when the staphylococcus albus is demon- 
strated under these conditions its presence in the circulating blood or its 
excretion by the sweat-glands can be inferred. But it is evident that 
such an inference is unwarranted without additional proof. 

There are various other white cocci, and also several species of yel- 
low cocci, both liquefying and non-liquefying, which are frequently 
found in cultures from the skin. Some of the yellow cocci can readily 
be mistaken for the staphylococcus pyogenes aureus, unless they are 
carefully studied in culture media. The staphylococcus pyogenes aureus 
may be found on the skin, as will be mentioned presently. 
X The kinds and the number of bacteria found upon exposed parts of 
the skin vary considerably according to the habits and the occupation of 
the individual. Of especial interest in this connection are the results of 
the examination of the skin of surgeons and others who come into con- 
tact with infected persons either during life or at the autopsy-table. We 
have found only exceptionally the staphylococcus pyogenes aureus upon 
the hands of those who do not come into proximity to surgical or infected 
cases, whereas we have many times found this micro-organism upon the 
hands of surgeons, their assistants, and surgical nurses. In examining 
the hands of those who use corrosive sublimate as a disinfectant it is 
necessary first to neutralize the sublimate with ammonium sulphide, as 
we have found that the sublimate may prevent the development of cuta- 
neous micro-organisms with which it has come into contact, although it 
has not killed them ; and this restraining influence may be manifest days, 
and even weeks, after the application of the sublimate. 

The length of time that the yellow pyogenic staphylococcus may 
persist upon the hands varies, and doubtless largely, according to the 
methods and extent of cleansing the skin. It certainly may persist for 
several days, although it may disappear in a few hours. It does not 
seem usually to grow down, as does the white epidermal coccus, into 
the deeper layers of the skin, so that ordinary methods of disinfection 
of the skin are likely to remove or destroy this organism. By rubbing 
or by the application of pressure the staphylococcus aureus may, how- 
ever, be pressed into the deeper layers, particularly into the hair-follicles, 
and there cause furuncles, as has been shown by the experiments of 
Garr6, Schimmelbusch, Wasmuth, and others. The view which has been 
advocated by some writers that it requires more thorough disinfection to 



BACTERIA OF THE SKIN. 253 

remove or destroy pathogenic bacteria accidentally or intentionally ap- 
plied to the skin than to kill the ordinary bacteria of the skin is not 
supported by experiments. The healthy skin in general is not a favor- 
able resting- or breeding-place to secure the long persistence of patho- 
genic bacteria, with the exception of the white epidermal coccus, which 
possesses relatively little pathogenic power under ordinary circumstances. 

The streptococcus pyogenes has been found less frequently than the 
staphylococcus aureus in cultures from the skin, and here too chiefly in 
cultures from the skin of infected patients or of those who have been in 
proximity to them. It is well to bear in mind that these pyogenic cocci 
are not necessarily limited to the immediate neighborhood of an infected 
wound or focus, but may occur on other parts of the body, as well as in 
' the air or on objects which have been near the patient. Thus Preindls- 
berger found the aureus in the dirt beneath the finger-nails of a patient 
with fracture of tlie femur, and the streptococcus pyogenes in the same 
situation in a patient with osteomyelitis femoris for which necrotomy 
had been performed. The complete disinfection of an infected Avound, 
even if that were possible, would not therefore furnish a guarantee that 
pyogenic cocci were not present upon the surface of the patient's body 
in other situations. 

The bacillus pyocyaneus is a common parasite upon the human skin. 
Miihsam ^ found it in the axilla and in the anal and inguinal folds of 
healthy persons in 50 per cent, of the cases examined. Probably local 
conditions were concerned in these observations, as others have not 
found this organism upon the healthy skin with such frequency. Al- 
though this organism may manifest important pathogenic activities, its 
presence in wounds is usually made evident chiefly by the green or blue 
discoloration of the dressings. It was formerly supposed to enter the 
wound from the air, but it doubtless is often derived also from the skin 
of the patient. 

The common intestinal bacterium, the bacillus coli communis, is of 
course often present on the skin about the anus. In abscesses in this 
situation it is often found either alone or associated with other bacteria. 
The colon bacillus may also be found upon the skin in other parts of 
the body. It is a widely-distributed bacterium outside of the animal 
body. It has repeatedly been found in wounds in different parts of 
the body. 

Skin contaminated with the soil, which, as is well known, contains 
in many situations abundant bacilli of tetanus and of malignant oedema, 
is likely to present these micro-organisms. This contamination relates, 
of course, especially to the hands, and in the case of those who go bare- 
foot or have holes in their shoes also to the feet. Maggiora was able to 
demonstrate the bacillus of malignant cedema in scrapings from between 
the toes of a person who had walked for half an hour in a garden with 
a torn shoe. It is not therefore in all cases necessary to suppose that 
the tetanus bacillus enters a wound from the object which causes the 
wound, for this bacillus may previously have been attached to the skin. 
It may in this connection be mentioned that the faeces of herbivorous 
animals often contain the tetanus bacillus, and in a condition more 

' Muhsara, cited by Schimmelbusch, Samml. kliniseher Vortrdge von Volkmann, Serie 3, 
Heft. ii. No. 62. 



254 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

likely to produce tetanus than when the bacillus is obtained from the 
soil. Buday ' has reported a case of tetanus fatal in twenty-four hours 
which followed the smearing of a wound with fasces. 

xThe smegma bacillus may be considered in connection with the cuta- 
neous bacteria. This bacterium is usually present in the smegma, and 
may be found about the penis, scrotum, vulva, and anus. Attention 
was first called to this bacillus by Ah'arez and Tavel and by Matter- 
stock in 1885, on account of its resemblance in morphology and staining 
reactions to Lustgarten's bacillus, which at that time was thought by its 
discoverer to be the specific cause of syphilis. Greater practical import- 
ance, however, belongs to the smegma bacillus at present on account of 
the possibility of mistaking it from its staining jiroperties for the tuber- 
cle bacillus, and there is reason to believe that such mistakes have been 
made in examinations of the urine and of secretions or exudates about 
the external genitals and the anus. The smegma bacillus resembles the 
tubercle bacillus in the pi'operty of retaining the staining d}e after such 
application of acids and alcohol that all known bacteria except the tu- 
bercle bacillus, the smegma bacillus, and the lejsrosy bacillus are decol- 
orized. This property jDrobably does not inhere in the smegma bacilli 
as such, but is due to the presence of chemical constituents of the 
smegma, although this point is not positively settled. In the opinion 
of the writer this peculiar staining reaction does not belong to only a 
single species of bacillus in the smegma, but to several, so that it is 
more proper to speak of smegma bacilli with this reaction. Mistakes 
are particularly likely to occur when the handy and popular Gabbet's 
stain for the tubercle bacillus is employed. The usual statement is that 
the smegma bacilli can be distinguished from the tubercle bacillus by 
less resistance to decolorizing agents, particularly to nitric acid, hydro- 
chloric acid, and alcohol, also to counter-stains ; and this often holds 
true. Nevertheless, smegma bacilli are sometimes encountered ^vhich 
are as resistant to these decolorizers as are tubercle bacilli. Especial 
attention should be given to the morphological appearances, as the size 
and shape of the oacilli often suffice for the distinction, although there 
is considerable diversity as regards this feature between the different 
smegma bacilli which resist decolorization. Although smegma bacilli 
may be present with pathogenic bacteria in lesions around the genitals 
and anus, they are not known to possess pathogenic capacity. 

Many bacteria are attached to the hairs of the body, "and particles 
ccmtaining bacteria may readily be detached from the liair. Robb has 
studied the bacteria which fall off from the hair of the head by move- 
ment or by combing the hair. They are identical with tJbose found on 
the skin, as might be expected. Haegler has cultivated pyogenic staph- 
ylococci from the hair of surgeons, and calls attention" to the possi- 
bility of such cocci falling from the hair into a wound or upon objects 
coming into contact with the wound during an operation. Wright has 
found the diphtheria bacillus on the hair of nurses in attendance on 
cases of diphtheria. 

The cerumen is rich in bacteria. Rohrer ^ isolated sixteen species of 
micro-organisms from the cerumen of fifty cases, but he has not attempted 

' Buday, Pester Med.-chir. Presse, 1894, No. 19. 
^ Eohrer, Archivf. Ohrmheilk., Bd. xxix. 



BACTERIA OF EXPOSED MUCOUS SURFACES. 255 

to identify any of these with previously-known bacteria, and his state- 
ments as to the existence of pathogenic bacteria in the cerumen are not 
based upon conclusive observations. 

Bacteria of Exposed Mucous Surfaces. 

The way is open for the access of micro-organisms to mucous mem- 
branes which cover parts which communicate with the outer world 
through the external orifices of the body. So far as temperature, moist- 
ure, and the presence of nutritive pabulum are concerned, the conditions 
are manifestly more favorable for the growth of bacteria upon mucous 
surfaces than upon the dry skin. These relatively favorable conditions 
for the development of micro-organisms upon mucous membranes are, 
however, counteracted in large measure by various mechanical and chem- 
ical influences which prevent the prolonged survival of most of the bac- 
teria which may enter through the external orifices of the body. There 
are, however, many bacteria which may multiply, or persist for a long 
time or indefinitely, upon certain mucous membranes in health, partic- 
ularly those of the alimentary canal and of the upper respiratory tract, 
and there are some bacterial species which find their natural home here. 
Some pathogenic bacteria may live upon certain mucous membranes 
without doing harm. 

The study of the bacterial flora of exposed mucous membranes in 
health and in disease has brought to light many points of surgical 
interest. 

Conjunctiva. — The bacteriology of the conjunctiva has been inves- 
tigated by many ophthalmologists, of whom may be especially mentioned 
Fick, Weeks, Leber, Felser, van Genderen Stort, Gombert, Bernheim, 
Hildebrandt, Franke, Marthen, and Bach.^ 

When one considers the exposed situation of the conjunctiva, it is 
surprising to find how small is the number of bacteria usually present in 
the conjunctival sac. Fick found, by microscopical examination of fifty 
healthy conjunctivae, bacteria in only eighteen, although in another series 
in which forty-nine healthy eyes of paupers were examined bacteria were 
missed in only six. A negative microscopical examination, however, 
indicates only that the number of bacteria is small, as then their presence 
may readily be overlooked without the aid of cultures. As a matter of 
fact, cultures from the healthy conjunctival sac usually furnish colonies 
of bacteria. Their number may be considerable, but it often happens 
that not more than three or four colonies develop from a loopful of fluid 
from the conjunctiva, and it is not very uncommon for culture media 
inoculated in this way to remain sterile. It is to be assumed that the 
conjunctival sac ordinarily contains bacteria. The secretion within the 
lachrymal glands is sterile. 

Bach describes twenty-six species of bacteria isolated in pure culture 
from the healthy or diseased conjunctiva. Of these, ten are liquefying 
cocci, nine non-liquefying cocci, five liquefying bacilli, one non-liquefying 
bacillus, and one cladothrix. Ten of the twenty-six bacteria were found 
to be more or less pathogenic when inoculated into the rabbit's cornea. 

■ L. Bach, " Ueb. d. Keimgehalt des Bindehautsackes," Archiv f. Ophthahnologie, Bd. 
xl. p. 130. This article contains the references to the other articles cited in the text. 



256 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

Pink yeast and mould fungi have also been cultivated from the con- 
junctiva. 

Bach considers that of these various bacteria only the staphylococcus 
pyogenes aureus and albus and the streptococcus pyogenes are demon- 
strated to be pathogenic for man, although the possibility that others in 
the list may be, pathogenic for man must be admitted. In a few instances 
the staphylococcus pyogenes aureus, and in more the albus, have been 
cultivated from the healthy conjunctiva. Cultures of the staphylococcus 
pyogenes aureus have been introduced into the healthy conjunctival sac 
of man and animals without causing inflammation. 
•\ Inasmuch as many micro-organisms must enter the conjunctival sac 
from the air, the edges of the eyelids, and from contact with the fingers 
and other objects, and as relatively few bacteria are found ordinarily in 
cultures from this part, it is evident that there must be some very efficient 
mechanism which rids the conjunctiva of most of the bacteria which enter. 
There are two principal agencies by which this may be accomplished — 
namely, mechanical removal through the naso-lachrymal duct, and the 
germicidal action of the lachrymal and conjunctival secretions. Some 
investigators have attached the greater importance to the former, others 
to the latter, of these agencies. Experiments have shou'n that each may 
be operative, but the mechanical removal has been shown to be especially 
efficient and prompt in its action. 

Van Genderen Stort has made experiments upon rabbits, and Bach 
upon man, by dropping pure liquid cultures of easily-identified bacteria, 
such as the Kielwater bacillus, the bacillus coli communis, the staphylo- 
coccus aureus, into the conjunctival sac, and then determining by cultures 
the length of time during which they can be demonstrated. Van Gen- 
deren Stort found after fifteen minutes the inoculated bacteria reduced 
to a small number, and at the end of an hour they had nearlv or entirely 
disappeared from the conjunctival sac. Cultures from the nose showed 
that they had been carried down the naso-lachrymal duct, and that after 
five minutes they were abundant in the cultures from the nasal cavity. 
Identical results were obtained by Bach in his experiments on human 
beings. In the experiment of Bach with the staphylococcus aureus, 
however, which was introduced in such number that the immediate 
plates from the conjunctiva contained countless colonies, there were still 
seventy-four colonies in the plates made after twenty-four hours. 

The same experiments were made after ligation of the naso-lachrymal 
duct. Under these circumstances the inoculated bacteria also disappeared 
from the conjunctival sac, but more slowly than when the duct was open. 
Still, after an hour most of the bacteria had been removed. It was found 
that they had been carried away by the lachrymal secretion which flowed 
over the eyelids. If the eyelids were closed by a bandage, the bacteria, 
with open nasal duct, rapidly passed down into the nose, and they did 
not appear to pass out bet\veen the closed eyelids. When, however the 
duct was closed, they appeared abundantly in the bandage. 

Bernheim has demonstrated that the tears possess considerable bacteri- 
cidal power over certain species of bacteria, and his results have been in 
part confirmed by the experiments of Marthen, Bach, and others. The 
staphylococcus pyogenes aureus is killed in moderate number, and the 
typhoid bacillus in larger number, by the lachrymal secretion. We 



BACTERIA OF EXPOSED MUCOUS SURFACES 257 

must therefore assign importance to this chemical action, as well as to 
the mechanical removal, in ridding the conjunctiva of invading bacteria. 
Neither of these agencies suffices to remove all of the bacteria. Some 
bacteria grow readily in the fluid of the conjunctiva. As has already 
been mentioned, the conjuctiva nearly always contains some bacteria. 
The orifices of the Meibomian glands, the cilia, and the edges of the eye- 
lids usually contain many bacteria, and these of course may readily enter 
the conjunctival sac. 

Bach was unable to demonstrate that bacteria introduced into the 
nasal cavity ever make their way up the nasal duct to the eye. 

It is difficult to obtain complete disinfection of the conjunctival sac. 
The number of bacteria may be greatly reduced, either by the application 
of antiseptics or by simple mechanical cleansing, combined with irriga- 
tion by an indifferent fluid, such as sterilized salt^solution. Bach obtained 
the best results by the latter procedure, by which in sixteen out of forty- 
two cases he rendered the conjunctiva sterile. 

The importance of familiarity with the saprophytes to be found on 
exposed mucous membranes is illustrated by the history of the so-called 
xerosis bacillus. This bacillus was discovered by Neisser in 1882 in 
xerosis of the conjunctiva, and was regarded by him as the cause of this 
disease. This conclusion was adopted by several subsequent investigators, 
who found this bacillus constantly present in xerophthalmia. This same 
bacillus has, however, been demonstrated by Schreiber, working under 
Neisser's direction, in various other affections of the eye, and also, 
although in small number, in the normal conjunctival sac. Neisser has 
therefore given his assent to the conclusion expressed by Schreiber •} 
" The so-called xerosis bacilli are to be regarded as saprophytes which 
are often present in the conjunctiva and its secretion, both in diseased" 
and healthy eyes, and they play no special r61e either in xerosis or in 
other diseases of the eye." 

The xerosis bacillus belongs to an interesting group of bacteria which 
are characterized by remarkable irregularities in size and shape — so-called 
involution forms — and by irregularities in staining, especially by the 
presence of deeply-staining isolated granules. It is not positively proven 
to form spores, although some of the isolated granules are interpreted 
as such by Ernst and by Neisser. To this same group belong the 
diphtheria bacillus of Loffler and the so-called pseudo-diphtheria 
bacilli. 

Mouth and Phaeynx.^ — All of the micro-organisms which may 
be present in the air, food, and ingested fluids may appear temporarily in 
the mouth. The number of bacteria which have been cultivated from 
the human mouth is very large. Miller has isolated over one hundred 
species. Freund has cultivated eighteen different chromogenic micro- 
organisms from the mouth. 

It is important to distinguish between the countless bacteria which 
may appear as transient visitors in the mouth and those Avhich find their 
permanent home there. A remarkable peculiarity of the constant inhabit- 

' Schreiber, Foriaehrilte der Median, 188S, p. 656. 

^ Miller, Die Mikro-orqamsmen der Mundhohle, Leipzig, 1889; David, Les Microbes de 
la Bouche, Paris, 1890. These valuable works present the most important results hitherto 
obtained by the investigators of the micro-organisms of the mouth. 
Vol, I— 1 7 



258 GENERAL BAOTEBIOLOOY OF SURGICAL INFECTIONS. 

ants of the saliva is that most of them will not grow in our artificial 
culture media. This produces often a striking discrepancy between the 
results of microscopical examination of the buccal secretions and those 
obtained by cultures. Cover-slip specimens may show an enormous 
number of bacteria, when cultures made from the same material may 
show very few or even no colonies. 

Miller enumerates the following as the constant buccal bacteria : 
leptothrix buccalis innominata, bacillus buGoalis maximus, leptothrix bue- 
calis maxima, iodococcus vaginatus, spirillum sputigenum, spirochcete 
dentium. None of these have been artificially cultivated. Bacillus buc- 
calis maximus and iodococcus vaginatus are stained violet by iodine 
solution. These bacteria are often present, with others, in carious teeth, 
in abscesses communicating with the mouth and pharynx, and in exudates 
on the mucous membranes of these parts, but they have not been proven 
to be pathogenic. 

The frequent presence of pathogenic bacteria in the healthy mouth is 
of great practical importance. The following pathogenic bacteria have 
been found repeatedly in this situation : micrococcus lanceolatus, strepto- 
coccus pyogenes, staphylococcus pyogenes aureus and albus, micrococcus 
tetragenus, bacillus pneumoniae of Friedlander, bacillus crassus sputigenus 
of Kreibohm, bacillus coli communis. Biondi, Miller, Kreibohm, Galippe, 
and others have found in the mouth additional pathogenic bacteria in 
isolated cases, mostly, however, with some morbid condition. 

The micrococcus lanceolatus was discovered by Sternberg in his saliva 
in 1880. Many names have been given to this bacterium, the more 
common synonyms being diplococcus pneumoniae, pneumococcus of 
Fraenkel and Weichselbaum, diplococcus lanceolatus, micrococcus of 
sputum septicaemia, and micrococcus pneumoniae cruposae (Sternberg). 
This micro-organism was found byNetter in a virulent condition in 15 to 20 
per cent, of the healthy persons whom he examined. It varies markedly 
in virulence, and it is probably present in a non-virulent condition in 
many cases. Indeed, Kruse and Pansini believe that the micrococcus 
lanceolatus is a regular inhabitant of the human mouth, although it is 
present in a virulent state in only about one out of five or six persons. 
As the lanceolate coccus, especially when its virulence is weak or absent, 
may grow in chains and present cultural characters of the streptococcus 
pyogenes, it is often difficult, if not impossible, to distinguish between 
these bacteria. 

The chief interest attaching to the frequent presence of the micro- 
coccus lanceolatus in the healthy mouth is that this bacterium is the 
cause of lobar pneumonia and of many cases of broncho-pneumonia. 
It may also be concerned in local inflammations of the throat, and as a 
primary or secondary invader may cause serositis and localized inflam- 
mations in various parts of the body ; but the streptococcus pyogenes is 
a more common cause of these lesions. 

Various virulent and non-virulent streptococci have been found in 
the mouth, both shorl^chained streptococci and long-chained forms corre- 
sponding to the two varieties, streptococcus brevis and streptococcus 
longus. The distinctions upon which these varieties were established by 
Von Lingelsheim are often inconstant, and do not serve for a sharp 
differentiation. The chief interest belongs to the presence in the mouth 



BACTERIA OF EXPOSED MUCOUS SURFACES 259 

and pharynx of the streptococcus pyogenes. Netter found the strepto- 
coccus pyogenes in seven out of one hundred and twenty-seven healthy 
mouths examined ; that is, in 5.5 per cent, of the cases. Dornberger 
found streptococci in the mouths of healthy children in 45 per cent, of 
the ninety-four cases examined. Widal and Besangon found streptococci 
constantly and in large number in the mouths of twenty healthy persons, 
and still more abundantly in the mouth and pharynx of forty-nine 
persons affected with various diseases. 

It often requires a painstaking examination to detect this strepto- 
coccus. The colonies are minute and pale gray, and in a plate crowded 
with other more striking colonies the former may escape recognition 
unless especial attention is given to them. If the secretions of the 
healthy mouth and throat be carefully examined both by cover-slip 
preparations and by agar plate-cultures, streptococci will be found with 
great frequency, if not regularly, although, as already mentioned, it is 
by no means easy to distinguish some of the streptococci from chain 
forms of the micrococcus lanceolatus. 

The number of streptococci is increased and their detection is much 
easier in most inflammatory conditions of the tonsils and pharynx. 
They are commonly associated with the diphtheria bacillus in diphthe- 
ria, and they are capable of causing all grades of tonsillitis and pharyn- 
gitis, from slight erythematous forms to pseudo-membranous and necrotic 
inflammations. 

Streptococci cultivated from the healthy mouth usually have little or 
no virulence as tested upon animals, and the same is often true of strep- 
tococci cultivated from the throat in various infections, local and gen- 
eral, although in these cases they are more likely to be pathogenic for 
animals. 

The streptococcus pyogenes is a common and dangerous invader of 
the deeper air-passages and lungs and of the internal parts of the body. 
The portal of entry is often the tonsils and throat, and predisposing 
causes are inflammations and other lesions of these parts, particularly 
when combined with other infectious diseases and constitutional disturb- 
ances. Under conditions little understood the mouth-streptococci may 
acquire enhanced virulence. 

The influence of predisposing causes as a factor in the etiology of 
infections is well exemplified by the fact that healthy mucous membranes 
harbor very frequently such pathogenic germs as the micrococcus lanceo- 
latus and the streptococcus pyogenes. These bacteria often, moreover, 
cause no serious disturbance in the repair of wounds and injuries involv- 
ing the mouth and naso-pharynx, although they must gain access to 
such wounds. They are, however, a standing menace in surgical ope- 
rations involving these parts, and they may seriously interfere with the 
healing of such wounds, or may under these circumstances set up pneu- 
monia and general infection. 

Staphylococci are found often in the healthy mouth and the throat, 
but the genuine pyogenic staphylococci do not appear to be j^resent with 
great frequency. Vignal, Netter, and Miller met the staphylococcus 
pyogenes aureus only in a comparatively small number of cases in their 
bacteriological examinations of the healthy mouth. It is found more 
frequently in various inflammations of the mucous membranes of this 



260 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

region, but it plays no such important r6le in these as does the strepto- 
coccus pyogenes. 

White liquefying cocci, often described as the staphylococcus pyog- 
enes albus, are found oftener than the staphylococcus aureus in the 
mouth and throat. Some of these have been shown to possess pyogenic 
power, and may be accepted as the staphylococcus pyogenes albus, but 
others are devoid of such power. 

According to the statements of Biondi, Miller, and others, the micro- 
coccus tetragenus, which was discovered by Koch and Gaffky in a 
phthisical cavity, is often present in the mouth. In a considerable 
number of cases examined by the writer it was absent. The frequency 
with which certain bacteria are present in the mouth probably varies 
considerably in different regions and according to the class of cases 
selected for examination. There are various species of tetragenous cocci. 
The pathogenic form of Koch and Graffky is designated by Boutron as 
micrococcus tetragenus septicus. This organism is present more fre- 
quently in abscesses in the neighborhood of the mouth and throat, par- 
ticularly those connected with carious teeth, than in abscesses in other 
parts of the body, although even in the former it is rarely present. 

The virulent diphtheria bacillus was found by Park and Beebe ' in 
the healthy throats of eight out of three hundred and thirty persons in 
New York who gave no history of direct contact with cases of diphthe- 
ria. Only two of these eight persons afterward developed diphtheria. 
They found non-virulent, but otherwise characteristic, diphtheria bacilli 
in twenty-four throats of the same group of persons, and pseudo-diph- 
theria bacilli in twenty-seven. 

The pseudo-diphtheria bacillus which is occasionallv found in the 
throat is devoid of virulence, and presents certain cultural peculiarities 
distinguishing it from the genuine diphtheria bacillus. It is not known 
to be pathogenic. There is much confusion in the use of the term 
"pseudo-diphtheria bacillus," and some writers have described under 
this name the genuine diphtheria bacillus devoid of virulence. There is 
probably more than one bacterial species which may be called pseudo- 
diphtherial bacillus. 

The mouth and adjacent parts are the most frequent portals of entry 
of the bacterium of actinomycosis. This organism is likely to lodge near 
carious teeth. 

Although the mouth and throat offer more favorable conditions for 
the prolonged existence of many micro-organisms than do other exposed 
mucous membrane, nevertheless of the vast hordes of micro-organisms 
which must gain access to the mouth only a small number actually per- 
sist there. The conditions are evidently unfavorable for the survival of 
the majority of bacterial species in this situation. Those which are unable 
to gain a foothold must sooner or later pass down into the stomach or 
intestine or out through the mouth and nose or perish within the body. 

The secretions in the mouth and throat, like most of the fluids of the 
body, possess some degree of germicidal power. Sanarelli^ found that 
the saliva is capable of killing in a short time a moderate number of 

' Welch, " Bacteriological Investigations of Diphtheria in the United States " Am. 
Jmirn. of the Med. Sciences, Oct., 1894. ' 

' Sanarelli, CentralbLf. Bakler., 1891, Bd. x. 



BACTERIA OF EXPOSED MUCOUS SURFACES. 261 

several pathogenic bacterial species. This was found to be the case with 
the staphylococcus aureus, the streptococcus pyogenes, the micrococcus 
tetragenus, the typhoid bacillus, and the cholera spirillum. The diph- 
theria bacillus, however, survived for twenty-eight to forty days, and the 
micrococcus lanceolatus grew well in saliva, although with rapid loss of 
virulence. 

E. Grawitz and StefPen' have confirmed this observation of Sanarelli 
as regards the pneumococcus, and have found that the virulence of this 
organism may be restored by cultivating it upon pneumonic sputum pre- 
pared as an artificial culture medium. They interpret this as indicating 
that the virulence of the pneumococcus may be enhanced by certain 
chemical changes in the composition of the sputum. 

There is reason to believe that the virulence of pathogenic bacteria in 
the mouth, notably of the micrococcus lanceolatus and the streptococcus 
pyogenes, may fluctuate, both in the direction of attenuation and of 
exaltation, but we are not acquainted with the conditions which control 
these changes. 

The salivary glands and ducts are free from bacteria, except near the 
orifice of the ducts. 

Eespieatoey Passages and Middle Ear. — In normal respiration 
the bacteria contained in the inspired air must enter the nasal cavities. 
The anatomical arrangement of the nasal passages renders these an im- 
portant filtering apparatus for the protection of the deeper air-passages. 
It has been shown by experiments of Wright that with a respiration of 
one litre of air per minute from three-fourths to four-fifths of the 
bacteria of the inspired air are retained in the nasal cavities and their 
adnexa. 

It has already been mentioned that most of the bacteria which enter 
the conjunctival sac are carried into the nose through the nasal duct. 
We should therefore expect that the nasal cavities would contain abun- 
dant micro-organisms. 

The bacteria of the healthy nose have been studied by E. Fraenkel, 
Loewenberg, Hajek, von Besser, Wright, Paulsen, Weibel, Deletti, and 
others, with much divergence in their results. Some have found few, 
others many, bacteria in the nose ; some have met frequently pathogenic 
bacteria, others rarely or not at all. 

Von Besser^ describes twelve non-pathogenic species isolated from 
the noses of thirty persons at work in the laboratory. In the same group 
of cases he found in the nose the micrococcus lanceolatus six times, the 
streptococcus pyogenes five times, the staphylococcus pyogenes aureus 
seven times. In the nasal cavities of twenty-eight convalescent hospital 
patients he found the micrococcus lanceolatus four times, and the strep- 
tococcus pyogenes, the staphylococcus pyogenes aureus, and the bacillus 
of Friedlander each once ; in twenty-three soldiers and servants, the 
micrococcus lanceolatus four times, the staphylococcus pyogenes aureus 
six times, the streptococcus, pyogenes once, and the Friedlander bacillus 
once. 

Wright' isolated from the nasal secretion of ten healthy persons the 

' Grawitz and Steffen, Berliner klin. Wochenschr,, 1894, No. 18. 

^ Von Besser, Ziegler's Beitrdge, Bd. vi. 

" Wright, New York Med. Journ., July 27, 1889. 



262 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

staphylococcus pyogenes albus six times, the aureus and citreus three 
times, the bacillus lactis aerogenes once, and the micrococcus tetragenus 
once. 

Paulsen^ made sixty-four cultures from the healthy noses of twenty- 
seven persons. Eleven of these were sterile, nineteen gave ten colonies 
or less, sixteen gave up to one hundred colonies, twelve several hundred 
colonies, and six furnished countless colonies. Cocci were found much 
oftener than bacilli. Only once did he find the streptococcus pyogenes. 
Pathogenic bacteria were not observed in any other of the normal cases. 
Upon cover-slip preparations he noted spirilla, and Weibel has cultivated 
a comma bacillus from the nose. 

Special interest attaches to the presence of capsulated bacilli in the 
nose, as these are found with great frequency, if not constantly, in 
ozsena. The ozaena bacillus of Abel ^ resembles closely the Friedlander 
bacillus, but is believed by him not to be identical with it. Whether or 
not this bacillus is ever found in the healthy nose is not established. The 
Friedlander bacillus and the lanceolate coccus have repeatedly been 
found in the nose, especially in inflammatory conditions. The rhino- 
scleroma bacillus is a capsulated bacillus much like the Friedlander bacil- 
lus, but differing from it by staining with Gram's method. We do not 
at present possess an entirely satisfactory differentiation of a group of 
capsulated bacilli to which Friedlander's bacillus, the ozaena bacillus, 
the rhinoscleroma bacillus, the capsulated bacillus of Pfeiffer, and some 
others belong. 

The diphtheria bacillus is constantly found in fibrinous rhinitis. 
Various bacteria, especially diplococci, have been found in the secretion 
of coryza. When this secretion is abundantly poured out, it often 
happens that cultures from several drops of it contain very few colonies 
or are sterile. 

Straus has recently made the important observation that the tubercle 
bacillus is often present in the nasal cavities of healthy persons who 
spend much of their time in proximity to tuberculous patients. He 
examined for tubercle bacilli the contents of the nasal cavities of those 
engaged about hospital wards containing consumptives. Twenty-nine 
such examinations were made by the inoculation of guinea-pigs. In 
nine cases the guinea-pig developed tuberculosis. Of these nine persons, 
six were healthy attendants occupied in such work as sweeping the floor 
and shaking bed-linen, one was a patient with a chronic non-tuberculous 
ailment, and two were medical students who spent several hours daily in 
the hospital. Xone of these individuals presented the slightest evidence 
of tuberculosis. These observations are even more significant than 
those of Comet as to the abundance and wide distribution of tubercle 
bacilli in the neighborhood of consumptives. 

Wurtz and Lermoyez have found that the nasal mucus posseeses con- 
siderable bactericidal capacity. 

Von Besser found bacteria abundantly in the larynx and bronchi of 
human corpses, but he demonstrated that after death the fluids from the 
mouth and naso-pharynx may readily penetrate even into the smaller 
bronchi, and moreover in his cases the lungs and air-passages were dis- 

' Paulsen, Cenlralhl. f. Bakler., Bd. viii. p. 344. 
'' Abel, ibid., Bd. xiii. p. 161. 



BACTERIA OF EXPOSED MUCOUS SURFACES. 263 

eased ; so that he attaches no importance to his observations as bearing 
upon the question of the presence of bacteria in these parts in health. 

Hildebrandt ' found that culture media inoculated with bits of the 
lung and of tracheal mucus from recently-killed rabbits usually remained 
sterile, and he concludes that practically all bacteria which enter with 
the air are retained in the upper air-passages and do not penetrate below 
the larynx. This protection, however, has its limits, as when the inspired 
air was loaded with fungus-spores these could be demonstrated after 
half an hour in the lungs. That foreign particles in the air may be 
conveyed into the lungs is evidenced by the coal particles regularly 
found in the lungs. 

Wargunin, in opposition to Hildebrandt, isolated nine different kinds 
of bacteria from the trachea, bronchi, and lungs of recently-killed 
healthy animals. 

The observations of the writer are in harmony with Hildebrandt's 
results as to the usual absence of bacteria, at least in sufficient number 
to be demonstrable by ordinary culture methods, in the bronchi and 
lungs of healthy animals. 

At autopsies on human beings bacteria, including the micrococcus 
lanceolatus and the streptococcus pyogenes, may be found in the lungs 
without noticeable lesion of this organ. 

The action of the ciliated epithelium and coughing would tend to 
drive out bacteria which may have entered the trachea and bronchi. 

The expired air is free from micro-organisms, except as these may be 
mechanically detached, as in sneezing or coughing. 

We are not informed as to the frequency with which bacteria are 
present in the healthy tympanic cavity. That bacteria may pass up the 
Eustachian tube into the middle ear is shown by the presence in otitis 
media of various micro-organisms often found in the mouth and naso- 
pharynx, notably the micrococcus lanceolatus, the streptococcus pyogenes, 
the Friedliinder bacillus, and the pyogenic staphylococci. There are of 
course other paths by which micro-organisms may be carried into the 
middle ear, as the lymphatic and blood-currents, and in meningitis from 
the cranial cavity. <» 

Netter found constantly in the middle ear of new-born infants, at au- 
topsy, bacteria, and among these were pathogenic forms to which he attrib- 
utes the frequent occurrence of middle-ear inflammations in infants. In 
autopsies upon one hundred and eight infants less than one year old 
H. Kossel found otitis media in eighty-fi-ve cases. The most common 
organism in these cases was a delicate bacillus, apparently identical with 
Pfeiffer's pseudo-influenza bacillus (38 cases). In addition were found 
the diplococcus pneumoniae (10), streptococci (4), thick bacilli (2), staphy- 
lococci (2), and the bacillus pyocyaneus (once). One case was tubercu- 
lous otitis. Some writers are of the opinion that changes often found 
in the middle ear of the new-born are post-mortem alterations. 

Stomach and Intestine. — The study of the micro-organisms 
present in the stomach and intestine presents many points of physi- 
ological and pathological interest, but we must confine our attention 
chiefly to those of surgical interest. "When we consider the relations of 
intestinal bacteria to various surgical affections, such as perforative and 

' Hildebrandt, Ziegler's Beilrdge, Bd. ii. 



264 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

other forms of peritonitis, appendicitis, and even infections remote from 
the intestinal canal, it is apparent that this subject claims the attention 
of the surgeon. 

The main sources of the micro-organisms of the stomach and intes- 
tine are the ingesta and the air. From these sources countless bacteria 
and fungi of all kinds are introduced into the aliraentarjr canal, but, as 
is true of other exposed mucous surfaces, only a limited number of 
species are capable of prolonged existence in this situation. 

The meconium of the new-born infant is sterile, but witliin twenty- 
four hours after birth it usually contains abundant bacteria. Although 
many varieties of bacteria may be found, Escherich has demonstrated 
a constant bacterial flora in the faeces of milk-fed infants. These con- 
stantly-present intestinal bacteria are the bacillus lactis aerogenes, pre- 
dominating in the small intestine, and the bacillus coli communis, pre- 
dominating in the large intestine. These bacteria remain throughout 
life as the obligatory and characteristic intestinal bacteria of man in 
health, and as they are frequent secondary invaders of the body in 
disease, and may be concerned in various surgical and other diseases, 
much practical interest attaches to them. 

• The bacterial flora of the small intestine, particularly in its upper 
part, is more varied, as tested by plate cultures, than that of the large 
intestine. In fact, the comparison of the results of microscopical exam- 
ination and of cultures from the stools indicates that a large number 
of the bacteria in the faeces are dead. 

As there is very little free oxygen in the intestinal canal, the con- 
ditions are not favorable for the multiplication of obligatory aerobes. 
Most of the bacteria found in the intestine are strict anaerobes or facul- 
tative anaerobes, but anthrax spores, which require oxygen for their 
germination, develop into bacilli in the intestinal canal. 

It is certain that pathogenic bacteria of many kinds often finS their 
way into the intestinal canal ; in 'fact, there is probably no pathogenic 
germ which may not in certain individuals and in certain times and 
places be present in the intestine. 

It is true that the acid gastric juice may kill many of the micro- 
organisms which enter the stomach, but there are many which resist its 
action. If we were to rely exclusively upon the results of experiments 
in the test-tube on the germicidal action of the acid gastric juice, particu- 
larly the very acid juice of some animals, we should consider this action 
a formidable obstacle to the passage of living bacteria into the intestine. 
But when we consider the insusceptibility of many bacteria to weak 
acids, the relatively slight and varying acidity of the human gastric juice, 
the absence at times of any acid in the stomach, the withdrawal in large 
measure from the direct and concentrated action of the gastric juice of 
bacteria contained in ingested masses of food and large volumes of fluid, 
and the rapidity with which the gastric contents may pass into the duo- 
denum, we can understand how micro-organisms, even those very sus- 
ceptible to acids, may find frequent opportunity to enter the intestine. 
Only a fraction, usually not more than .05 to ."l per cent., of the total 
acidity of the stomach is due to free hydrochloric acid, and the proteid 
hydrochlorides possess very little bactericidal power. 

Many organisms can gro^^t.in tlie human stomach even when it is very 



BACTERIA OF EXPOSED MUCOUS SURFACES. 265 

acid, as has been shown by Gillespie.^ The number and variety of 
micro-organisms which have been isolated from the human stomach 
by Macfadyen, Abelous, Oppler, Gillespie, and others are very great, 
but it would serve no useful purpose to enumerate them here. The 
bacillus lactis aerogenes, the bacillus coli communis, and the pyogenic 
cocci may be specified as having been repeatedly found in the healthy 
stomach. 

The list of pathogenic bacteria which have been found in the intes- 
tinal contents is a long one. Many are present only accidentally and as a 
transient phenomenon. Some are found with such frequency as to merit 
special notice. In general, the conditions are not favorable for exten- 
sive multiplication of most pathogenic micro-organisms in the healthy 
intestine. 

Pyogenic cocci are rarely absent from the intestine. They are often 
present in such small number as to escape detection, but the great 
frequency with which these cocci, particularly the streptococcus pyogenes, 
are found in the exudate of perforative peritonitis, where they can rapidly 
multiply, shows that they are common inhabitants of the intestine. 
Gessner found a pathogenic streptococcus, probably identical with the 
streptococcus pyogenes, in large numbers in the duodenum of six persons 
out of eighteen examined at autopsy. 

The bacillus pyocyaneus and the proteus bacilli are also often present 
in the intestine. The tetanus bacillus and the bacillus of malignant 
cedema are regular inhabitants of the intestine of herbivorous animals. 
The micrococcus lanceolatus has been found repeatedly in the human 
intestine, likewise the bacillus pyogenes fcetidus. The bacillus aerogenes 
capsulatus has been found by the writer in the intestine in two cases of 
perforative peritonitis with- production of gas. The occurrence of intes- 
tinal actinomycosis and of perityphlitis actinomycotica shows that the 
actinomyces may find its way into the intestine. 

There are various other pathogenic 'bacteria which have been occa- 
sionally found in the intestine, but those which have been mentioned are 
the ones of chief surgical interest. The specific intestinal infections of 
typhoid fever, cholera, tuberculosis, and anthrax are not considered here. 
The amceba dysenterise, on account of its relation to abscess of the liver 
and lungs, deserves mention. 

In this connection it may be stated that the bile in the normal bile- 
ducts and gall-bladder is to be regarded as free from bacteria. Under 
various conditions, however, the colon bacillus and other bacteria, par- 
ticularly the pyogenic cocci, often wander into the biliary passages. The 
writer has found very frequently the colon bacillus in cultures made from ■ 
the interior of gall-stones. It is not uncommon at autopsies to find the 
colon bacillus, less frequently pyogenic cocci, particularly streptococci, 
in the bile without any alteration in the bile or evident lesion to explain 
the migration of these bacteria. 

Contrary to an old idea, the bile has not been found to possess any 
decided germicidal property, at least as regards most bacteria. 

Gei^ito-ueinary Tkact. — It has been shown by Lustgarten and 
Mannaberg, Rovsing, Steinschneider with Galewsky, Petit and Wasser- 

' Gillespie, " The Bacteria of the Stomach," The Journal of Pathology and Bacteriology, 
vol. i. p. 279. Here can be found references to the litesature of this subject. 



266 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

mann, and Hofmeister * that the healthy male urethra always contains 
bacteria. These are abundant and varied in the fossa navicularis, and 
diminish rapidly in number and kind toward the posterior part of the 
urethra. How far back they extend is not positively known. They 
were found by Hofmeister as far back as eight centimetres from the 
external orifice under conditions making it probable that they existed at 
this point, and were not simply pushed back by the sterilized glass tube 
which was introduced for the passage of the inoculating wire. Urethral 
bacteria are usually present in urine voided after sterilization of the 
meatus and fossa, even in the urine passed toward the end of micturition. 

Lustgarten and Mannaberg by microscopical examination of the 
normal male urethra distinguished ten different kinds of bacteria — 
namely, four bacilli and six cocci. Among the bacilli was the smegma 
bacillus, which has already been mentioned in describing the bacteria of 
the skin (page 254). Among the cocci was a diplococcus which they 
describe as identical in form and staining reactions with the gonococcus. 
They isolated in cultures seven species of cocci, white and yellow. 
Among these cocci was found the staphylococcus pyogenes aureus. They 
observed that the common urethral saprophytes were incapable of causing 
ammoniacal fermentation of the urine, and that they died when planted 
in urine. 

Rovsing, in opposition to most other investigators, found in the 
normal urethra pyogenic and non-pyogenic bacteria capable of fermenting 
urine and identical with many of the bacteria found in cystitis, so that 
he concludes that the usual source of the bacteria causing cystitis is from 
the urethral flora and not from the air bacteria. 

Steinschneider describes four species of diplococci, identical with 
forms previously recognized by Lustgarten and Mannaberg, as occurring 
in the normal urethra. Of these, a milk-M'hite diplococcus, which was 
met in 87 per cent, of the eighty-six healthy and gonorrhoeal cases 
examined, is regarded as the most common bacterium of the urethra. 
Next in frequency is an orange-yellow diplococcus found in 44.2 per 
cent, of the cases. These two species are stained by Gram's method, and 
need not be confounded with the gonococcus. Steinsclmeider isolated 
from three cases a grayish-white diplococcus, and from one case a lemon- 
yellow diplococcus, which were decolorized by Gram's stain and which 
may correspond to Lustgarten's pseudo-gonococci. He concludes that in 
only 5 per cent, of the cases are diplococci found which are decolorized 
by Gram. 

Petit and "Wassermann, whose methods were open to objection, culti- 
vated from the normal urethra of four persons five cocci, six bacilli, 
two sarcinse, and two yeast-fungi. They did not find a pseudo-gono- 
coccus. 

Hofmeister did not find the normal urethral flora as varied as have 
some observers. Two species of diplococci — viz. a non-liquefying white 
or yellow, large coccus and a liquefying, smaller, gray coccus — he regards 
as regular inhabitants of the urethra. An orange-yellow and an opaque 
white liquefying diplococcus he isolated, each from two cases. None of 
these four diplococci from recent cultures were decolorized by Gram, but 

' Hofmeister, FortMhritte der Meclicin, 1893, Nos. 16 and 17. Eeferences to other arti- 
cles cited are contained in this article. 



BACTERIA OF EXPOSED MUCOUS SURFACES 267 

he states that he repeatedly found in cover-glass specimens from the ure- 
thra diplococci which were decolorized by Gram. Once he found the 
staphylococcus aureus. The normal urethral flora he considers to be 
non-pathogenic and incapable of surviving long in the urine, although 
pathogenic bacteria may accidentally be present in the healthy urethra. 

The occurrence of the so-called pseudo-gonococci, as first described 
by Bumm and Lustgarten and Mannaberg in healthy and diseased ure- 
thrse, is of importance in reference to the diagnosis of gonorrhoea by 
microscopical examination. If all of the well-known points, as to the 
morphology, staining reactions, and enclosure and arrangement within 
cells, characterizing the gonococcus be observed, most authorities believe 
that a mistake in diagnosis is possible only in a very small number of 
cases, if at all. Undoubtedly a microscopical diagnosis of the gono- 
coccus has been made in some cases upon insufficient evidence, and it 
must be admitted that a positive microscopical diagnosis is sometimes 
attended with great difficulties. We now possess methods which enable 
us without serious practical difficulties to isolate and study the gono- 
coccus in cultures. 

It cannot be said that investigations have determined satisfactorily 
the question as to the relative frequency with which the bacteria of cys- 
titis are derived from the urethra or are introduced from without the 
body. As the bacillus coli communis or the bacillus lactis aerogenes is 
one of the most common bacteria in cystitis, the infection may often be 
from the intestinal canal through the blood-current by way of the kid- 
neys ; some believe more directly by continuity or by the lymphatic stream 
from the rectum. These bacilli are, however, widely distributed outside 
of the body, and may be present around the genitals. 

Although the results of the bacteriological examination of the healthy 
urine are contradictory, the weight of evidence is decidedly in favor of 
the view that the urine in the bladder in health is free from bacteria, 
and that if urethral saprophytes, or even some pathogenic germs, gain 
entrance to the bladder, they do not long survive in a healthy person. 

The female urethra contains bacteria, and the anatomical conditions 
are more favorable than in the male for the passage of the urethral 
bacteria into the bladder. Von Gawronsky in sixty-two cases examined 
found bacteria in fifteen — namely, the streptococcus pyogenes (3), the 
staphylococcus aureus (8), staphylococcus albus (1), the bacillus coli com- 
munis (2), the bacillus tholoeideum (1). This last bacillus is probably a 
pathogenic variety of the bacillus lactis aerogenes. It is stated that the 
urethra in these cases was normal. 

The vagina contains bacteria in varying number and kind. The 
cervix and uterus are normally free from bacteria. The absence of bac- 
teria from the uterus is not easily explained, but it has its analogy in the 
absence of bacteria from various other canals and cavities which com- 
municate with passages containing bacteria, as, for example, from the 
bladder and the bile-ducts. The factors usually cited in explanation of 
this important provision of nature are mechanical hinderances to the 
penetration of bacteria resulting from the anatomical structure of the 
parts and the germicidal properties of the secretions. The principal 
emphasis is usually laid upon the latter factor. 

The bacterial flora of the normal vagina contains various bacilli and 



268 OENEBAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

cocci, which do not grow on our ordinary culture media, but can be rec- 
ognized by microscopical examination. Doederlein' has described a 
non-pathogenic bacillus or a group of bacilli which he has cultivated 
upon a specially prepared acid medium, and which are characterized by 
marked acid fermentation of sugar. These vaginal bacilli are regarded 
by Doederlein as the only bacteria to be found regularly in the normal 
vaginal secretion, and upon their presence or absence he has based his 
distinction between normal and pathological vaginal secretions. It has, 
however, been shown by Kronig and Menge that Doederlein's bacillus 
is often absent from the normal vagina, and that it cannot, therefore, 
serve as a distinguishing character of the normal secretion. 

According to Kronig ^ and Menge ^ the regular bacterial inhabitants 
of the normal vagina are obligatory anaerobes, and can be cultivated 
only in anaerobic cultures. They do not describe in detail the characters 
of these vaginal anaerobic bacilli and cocci, but they say that they are 
non-pathogenic. In microscopical preparations Menge found in the 
normal vaginal secretion of non-pregnant women bacilli more abun- 
dantly than cocci, but the latter were never missed. He found Doeder- 
lein's bacilli in the minority of cases, and more frequently short, thick 
rods and delicate, thin, curved rods. 

According to Menge, bacteria capable of cultivation in alkaline 
aerobic culture media are present abundantly near the outlet of the 
vagina, but are usually absent, and when present only few, in the upper 
part of the normal vagina. He found only once out of fifty cases exam- 
ined a pyogenic coccus. This was the streptococcus pyogenes, which 
existed as a persistent organism throughout the vaginal canal of a non- 
pregnant woman with gonorrhoea of the cervix and thin cervical dis- 
charge. The reaction of the vaginal secretion was alkaline. 

Diplococci similar to those from the urethra already described occur 
also in the vagina, and what was said in that connection as to pseudo- 
gonococci applies here. Koplik * has isolated from the normal vagina 
of children a white diplococcus, and from the vaginal discharge in 
simple, not gonorrhceal, vulvo-vaginitis in children two white diplo- 
cocci and a yellow diplococcus. None of these were decolorized by 
Gram's method or need be mistaken for the gonococcus. 

The question as to the occurrence of pathogenic organisms in the 
normal vagina has been and is still a subject of vehement controversy 
among obstetricians, who are divided into two camps as to the desira- 
bility of antiseptic irrigations of the vagina and as to the frequency of 
so-called auto-infection as a cause of puerperal infections. The question 
is also of interest to the surgeon in relation to hysterectomy and in 
general to operations involving the vagina and uterus. 

The results of different investigators on this point have been ex- 
tremely divergent, and, notwithstanding the large amount of work done, 
it is not possible at present to express a final judgment. Some inves- 
tigators have found pyogenic bacteria frequently in the vagina of preg- 
nant women. Thus, Steffeck found pus-producing organisms in 41 per 

' Doederlein, Das Schddensekret, u. s. w., Leipzig, 1892. 

' Kronig, Deutsche med. Wockenschrift, Oct. 25, 1894 

' Menge, ibid., Nov. 15, 22, 29, 1894. 

* Koplik, Journal of Cutaneous and Genito- Vnnary Diseases, June and July, 1893. 



BACTERIA OF EXPOSED MUCOUS SURFACES. 269 

cent, of the twenty-nine pregnant women examined. Others have failed 
to find pyogenic bacteria, with the exception of the gonococcus, in all of 
the cases examined, or have met them only exceptionally. Most of the 
later investigations in which a proper technique was adopted are in 
accord as to the infrequency with which pathogenic bacteria, with the 
exception of the gonococcus, are to be found in the vagina of either 
pregnant or non-pregnant women. 

In a bacteriological examination of one hundred and ninety-five preg- 
nant women Doederlein found in 55.3 per cent, acid normal vaginal 
secretion, according to his definition. The only bacteria were the acid- 
producing vaginal bacilli. In 44.6 per cent, of the cases he found what 
he calls pathological secretion, which was feebly acid, neutral, or alka- 
line, and contained various bacilli and cocci. The streptococcus pyog- 
enes he found in 9.2 per cent, of the so-called pathological secretions, 
or in 4.1 per cent, of the one hundred and ninety-five cases examined. 
To the staphylococci present he attributes no importance in the causation 
of puerperal fever. The oi'dium albicans is often found in the vagina, 
but is without significance as a cause of primary infection. 

Kronig found the vaginal secretion of all the pregnant women (about 
five hundred) whom he examined to be acid, the intensity of the reaction 
varying in different cases. The bacterial flora was of the same general 
character as that already described for the normal vagina. In no case 
did he find the streptococcus pyogenes or pyogenic staphylococci. His 
conclusion, that the streptococcus pyogenes and the pyogenic staphylo- 
cocci are never present in the vagina of pregnant women, and that if 
they should enter they must of necessity be quickly destroyed, cannot 
be accepted without discrediting the results of othei' competent investi- 
gators, but we may admit that they are present only exceptionally. 

Experiments have been made by Kronig and Menge proving that 
bacteria, including the streptococcus pyogenes and pyogenic staphylo- 
cocci, introduced, even in large number, into the vagina of pregnant or 
non-pregnant women, disappear in a short time. Thus, Kronig found 
that the bacillus pyocyaneus disappeared from the vagina of pregnant 
women in from ten to thirty hours, the staphylococci in from six to 
thirty-six hours, and the streptococcus pyogenes, with which only three 
experiments were made, within six hours. No difference was observed, 
as to the rapidity with which these foreign organisms disappeared, 
between the normal and pathological secretions in Doederlein's sense, 
including those containing gonococci. Menge found in non-pregnant 
women that the bacillus pyocyaneus disappeared from the vagina on the 
average in twenty-one hours, the staphylococcus pyogenes aureus in 
twenty-six hours, and the streptococcus pyogenes in twenty-two hours. 
In only one case did the vagina become infected, and this was with the 
staphylococcus aureus in consequence of an accidental injury to the wall. 
In the other cases the bacteria immediately after their introduction began 
to disappear. In most instances an increase in the leucocytes in the 
vagina was observed. 

Menge has attempted to discover the factors concerned in the pro- 
duction of this powerful bactericidal property of the vaginal secretion. 
He attaches some importance to the acid reaction to which Doederlein 
had called attention as the essential factor, but this cannot be the sole or 



270 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

the principal factor, as the vaginal secretion of non-pregnant women, 
although usually acid, may be alkaline, and the bacteria disappeared 
about as rapidly from the alkaline as from the acid secretion. We 
cannot at present give any satisfactory explanation of the bactericidal 
properties of the vaginal secretion. 

Irrigation of the vagina with water or with antiseptics diminished 
the rapidity with which bacteria introduced into the vagina disap- 
peared. 

Bacteria introduced into the cervix uteri likewise disappeared in a 
short time. The secretion here is alkaline. 

As a result of the investigations of numerous observers we may con- 
clude that the normal vagina of pregnant and non-pregnant women may 
contain pathogenic bacteria. With the exception of the gouococcus, 
such bacteria are not often present, and the vaginal secretion does not, 
as a rule, permit the prolonged survival of most of the bacteria, includ- 
ing pathogenic forms, which may enter. Powerful as these normal de- 
fences are, they may, however, be overthrown under conditions which 
we now only imperfectly understand. 

Much emphasis has been laid upon the fact that pyogenic cocci occa- 
sionally found in the vagina have manifested, with few exceptions, little 
or no virulence when inoculated into animals. It should, however, be 
remarked that the same negative result of the animal experiment some- 
times follows the inoculation of streptococci cultivated from cases of 
puerperal infection. The animal experiment is not decisive as to the 
possibilities of these pyogenic bacteria in man, and it has been proven 
that pyogenic cocci without virulence for animals may infect human 
beings.' 

Bacteria in Woman 's Mii.k. — Serious errors of interpretation of 
their observations have been made by several investiga;tors of the subject 
of excretion of bacteria by the milk, by not recognizing the fact that milk 
obtained from the breasts of healthy women regularly contains bacteria. 
The milk as secreted by the gland is undoubtedly sterile in health, but 
bacteria derived from the sldn are mingled with the milk. These bac- 
teria gain access to the milk in the lacteal ducts within the nipple. By 
far the most common of these bacteria is the staphylococcus epidermidis 
albus, described by investigators of this subject as the staphylococcus 
pyogenes albus. This coccus is a regular inhabitant of the milk in the 
lacteal ducts near their outlets. Surprise has been expressed by Honig- 
mann^ and others that of all the cutaneous bacteria this should be usually 
the predominant or the only one found in the milk, but it appears to the 
writer that his investigations as to the behavior of this organism in the 
skin explains satisfactorily the appearance of this coccus in the milk. 
Of all the cutaneous bacteria, this is the only one which penetrates regu- 
larly into the deeper layers of the epidermis and into the glandular 
appendages of the skin. Occasionally other bacteria, also derived from 
the skin, are present in the milk. The staphylococcus pyogenes aureus 

1 A full review of the bacteriological literature of the subject of puerperal auto-infec- 
tion up to the date of its publication, together with the report of original observations, 
will be found in a paper by J. Whitridge Williams in Tlie American Journal of the Med- 
ical Sciences, July, 1893. 

' Honigmann, Zeitsehnft fur Hygiene, Bd. xiv. p. 207. 



SOURCES OF THE BACTERIA IN SURGICAL INFECTIONS. 271 

lias been found in the milk of healthy women in a number of 
instances. 

It is not known how far up the lacteal ducts this normal bacterial 
flora extends. It is probable that the mammary gland conforms in this 
matter to the behavior of other glands whose ducts open upon surfaces 
containing bacteria, and that bacteria in demonstrable number are found 
only in the excretory ducts near their outlets. 

As the^aphylococci normally present in the milk have the property 
of coagulating milk, it can hardly be that any considerable multiplication 
of these bacteria occurs in the milk within the lacteal ducts. Fokker 
observed a limited germicidal eifect of fresh milk in some cases, but 
Honigmann in a larger number of experiments with proper technique 
was unable to determine any such property, even as regards the typhoid 
and the cholera bacilli, which are readily killed by blood-serum. 

Sources op the Bacteria in Surgical Infections. 

Internal Sources. — We have learned that pathogenic bacteria, and 
particularly the pyogenic micrococci, may be present upon the skin and 
various exposed mucous membranes of healthy human beings. These 
bacteria are of course derived primarily from external sources, but some 
of them may live for a long time or indefinitely on exposed surfaces of 
the body, and are found here so often that it is proper to recognize the 
patient's own body as one source of the bacteria concerned in surgical 
infections. 

Internal sources of wound-infection are in general less commonly 
operative and less dangerous than the external sources. One e:^planation 
of this is that the pyogenic bacteria commonly found in the healthy body 
are often less virulent than those derived from many external sources. 
The streptococcus pyogenes when cultivated from healthy mucous mem- 
branes is often of very slight or no virulence, as tested upon animals, 
although occasionally highly virulent streptococci are found under these 
circumstances. The pyogenic staphylococci, and particularly the sta- 
phylococcus albus, are often of greatly attenuated virulence when isolated 
from the exposed surfaces of healthy persons. The lanceolate micro- 
coccus is present in a virulent state in the mouths of only about 15 per 
cent, of healthy persons, although it is oftener present in a non-virulent 
condition. The bacillus coli communis obtained from healthy faeces is 
usually of very slight pathogenic power. 

There are various influences which may be cited to explain the 
relatively slight virulence of many of the pathogenic bacteria present in 
the healthy body. Among the most apparent are the struggle for exist- 
ence with the regular saprophytic flora of the body, the influence of the 
products of the latter organisms, and especially the antibacterial proper- 
ties of the fluids, secretions, and living cells of the body. That under 
circumstances which we at present little understand the bacteria of the 
body may acquire unwonted virulence seems certain. 

Highly virulent staphylococci and streptococci may be present on the 
exposed surfaces of the healthy body without doing any harm. The pro- 
tection of the body from infection with the pathogenic bacteria which it 
often harbors is due not so much to the lowered virulence of these bac- 



272 GENERAL BACTEBIOLOOT OF SUBOWAL INFECTIONS. 

teria as to the defences which have been set up against their invasion and 
to the local and general resistance offered to their growth. 

These defences may, however, be overthrown, and under these cir- 
cumstances pathogenic bacteria originally present on exposed surfaces of 
the body may cause various local and general diseases. The unsatisfac- 
tory term "auto-infection" is sometimes applied to diseases thus pro- 
duced. 

The internal organs and fluids of the healthy body are normally free 
from bacteria. Bizzozero and Eibbert have found bacteria, often within 
cells, regularly in the lymph-follicles of the normal rabbit's caecum, and 
Bizzozero has found spirilla often in the epithelial cells lining the necks 
of the gastric tubules in dogs. These are the only examples known of 
the presence of bacteria in the living cells of the perfectly healthy body, 
and here the bacteria have penetrated only a short distance beneath the 
free surface. 

It is probable that pathogenic as well as other bacteria occasionally 
get into the tissues and circulation of healthy persons without doing any 
harm. It is claimed by some that the invasion of bacteria into the 
healthy body is not uncommon, and this doctrine is called latent micro- 
bism by some French writers. The occasional occurrence of suppuration 
in a simple fracture of bone or in other injured parts remote from an 
exposed surface is best explained, at least in many cases, by the lodge- 
ment of pyogenic bacteria which have been carried from an exposed sur- 
face to the part by the blood or lymphatic current, and which presumably 
would have done no harm without the presence of a locus minoris resist- 
entiee. The infrequency of this event, however, indicates that the pres- 
ence of pathogenic bacteria in the internal organs and fluids of the healthy 
body is exceptional. 

Can a wound become infected by bacteria conveyed to it by the 
circulating blood? This may happen in individuals already infected, 
although, even when it is certain that pyogenic cocci are present in the 
circulating blood, a wound may heal without suppuration. The possi- 
bility of the infection of a wound in a previously uninfected person by 
bacteria conveyed by the blood-current cannot be denied, but we possess 
no stringent proof of such an occurrence, and all experience goes to show 
that wound-infection from this source must be very exceptional, if it 
occurs at all. 

With proper technique the surgeon has, as a rule, little to fear from 
the bacteria of the patient's skin as a source of infection of operative 
wounds. The only bacterium of the skin which is not usually destroyed 
by thorough disinfection of the surface is the staphylococcus epidermidis 
albus, which lies often deeper than can be reached by any of the prac- 
ticable methods of cutaneous disinfection. This coccus is found with 
great frequency in wounds treated aseptically or antiseptically, but ordi- 
narily it does not interfere with the process of repair. Under certain 
circumstances, particularly when foreign bodies are introduced into the 
wound or when there is strangulated tissue in the wound, it may cause 
rise of temperature and suppuration. It is the most common cause of 
stitch-abscesses. It is often associated with other bacteria in suppura- 
tion of external wounds and in inflammations involving the skin. It is 
identical with, or simply a variety of, the staphylococcus pyogenes albus, 



SOURCES OF THE BACTERIA IN SURGICAL INFECTIONS 273 

but for reasons which have been stated the latter name seems inappro- 
priate for this ordinary, harmless skin coccus. This white staphylo- 
coccus is a widely-distributed organism, and it may enter a wound from 
without as well as directly from the surface of the body. 

The source of the bacillus pyocyaneus in wounds is often from the 
skin of the patient, but this is a widely-distributed organism, and it 
may also enter from without. 

The mucous membranes which normally harbor bacteria on their sur- 
face cannot be completely disinfected by any practicable methods, al- 
though it is possible to reduce the number of bacteria, in some situa- 
tions more readily than in others. The utility of attempting before 
operation disinfection of a mucous surface — as, for example, in opera- 
tions involving the conjunctiva, mouth, rectum, and the lower genito- 
urinary tract — must be determined by experience, and on this point the 
views of surgeons are not in harmony. 

Bacteria cannot be completely kept out of wounds of exposed mucous 
membranes. The kinds of bacteria in the patient's bod}' which are 
likely to enter such wounds and the special conditions relating to the 
bacterial flora of the different mucous membranes have already been 
described. Although wounds involving such mucous membranes as those 
of the mouth and intestine, which contain vast numbers of bacteria, 
including often pyogenic varieties, often heal satisfactorily, and even by 
first intention, the surgaon has no such guarantee of securing primary 
union as in operative wounds through the skin. The fact that these 
wounds often heal quickly and without suppuration demonstrates that 
the mere presence of certain bacteria, even in large number, in a wound 
does not necessarily interfere with healing. It also supports the view 
already advocated that the pyogenic cocci often present on certain exposed 
mucous surfaces are usually of weakened virulence. But the main factor 
is, after all, the vital resistance of the living tissues to bacteria, including 
many virulent species. 

The pathogenic bacteria often present on the exposed surfaces of the 
healthy body are, however, of surgical interest, not so much as a source 
of primary wound-infection, but rather as the specific agents of infection 
in various local and general surgical diseases. As examples of local 
diseases of this category may be cited otitis media, appendicitis, per- 
forative and other forms of peritonitis, some cases of cystitis, and cer- 
tain abscesses. The pneumonias, localized abscesses, pysemia, and sep- 
ticseraia which are such frequent complications of diphtheria and certain 
general diseases, as typhoid fever and other infectious fevers, are due in 
many instances to the secondary invasion of pathogenic bacteria, par- 
ticularly pyogenic cocci, normally present on mucous membranes. It is 
chiefly from the mouth, tonsils, pharynx, and intestine that these invaders 
enter the body. The primary disease is often one which is attended by 
some lesion of the mucous membrane which opens the way for the pass- 
age of the micro-organism. But it is not enough for the gate to be 
thrown open. The defenders within must be overcome. Hence it is 
particularly in conditions where the vital powers of resistance are lowered 
that we meet with affections caused by the invasion of pyogenic bacteria 
from the exposed surfaces of the body. That under these conditions, as 

Vol. I.— 18 



274 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

well as under others, attenuated bacteria of the body may become exalted 
in virulence is highly probable. 

The term " auto-infection " is associated particularly with the discus- 
sions on the causation of puerperal fever. The bacteriological data 
entering into this discussion have been given in describing the bacteria 
of the vagina. The evidence is contradictory, but on the whole is 
opposed to recognizing so-called auto-infection as a cause of puerperal 
fever, save in a small proportion of cases. 

The bacteria most often found in cystitis are such as might readily 
gain entrance at times to the healthy urethra, but in most cases of this 
disease, as in so many others, an essential etiological factor is some pri- 
mary damage to the part, which permits the survival and growth of the 
invading micro-organisms. 

^ The most common secondary invader of the body is the bacillus coli 
communis. The first observations of the general invasion of the inter- 
nal organs of the body by the colon bacillus were made by the writer 
and reported in May, 1890. We have found in 40 per cent, of the 
autopsies at the Johns Hopkins Hospital the colon bacillus in one or 
more of the internal organs, those most fi-equently invaded being the 
lungs, kidneys, liver, mesenteric glands, and gall-bladder. In the great 
majority of these cases the colon bacilli were present without any 
organic lesion which could be referred to them. Intestinal lesions 
were found in 75 per cent, of our post-mortem cases of invasion of the 
colon bacillus. Very little importance is to be attached to the demon- 
stration of this bacillus in internal organs of the body at autopsies in 
cases without any lesion which can be referred to it. 

The fact that the colon bacillus is found with great frequency in 
internal organs of -the body after death from all sorts of causes, and 
without doing any manifest injury, necessitates caution in the interpreta- 
tion of cases where its presence is associated with definite lesions. That 
in some of the cases reported as infections by this bacillus its presence 
was only that of an accidental, secondary invader seems to the M^riter 
certain. There can be no doubt, however, that under certain conditions 
the colon bacillus may be pathogenic. It is prone to settle in parts 
already damaged either by some other micro-organism oi^v some non- 
infectious agent. In forty-eight cases of acute inflammation, of various 
kinds and situations, in which we found the colon bacillus, it was the 
sole organism present in only fourteen. In the majority of cases of 
appendicitis and of perforative peritonitis we have found associated Mith 
the colon bacillus other bacteria, and particularly the ordinary pyogenic 
cocci. There is reason to believe that the highly resistant colon bacillus 
may survive in an inflamed part after the primar}- organism which 
started the trouble has died out or has been crowded out by the invader. 

The colon bacillus has been repeatedly observed alone or in combina- 
tion with other bacteria in wounds. That it may be the primary infec- 
tious agent in various surgical and other inflammations in diff'erent parts 
of the body is established by numerous observations. 

The bacillus lactis aerogenes, which most investigators no longer 
attempt to separate sharply from the bacillus coli communis, is likewise 
a common invader from the intestinal tract under conditions similar to 
those relating to the colon bacillus and with similar pathogenic effects. 



SOURCES OF THE BACTERIA IN SURGICAL INFECTIONS 275 

The streptococcus pyogenes is a far more important cause of surgical 
infections than is the colon bacillus. It is more commonly present than 
other pyogenic cocci in appendicitis, peritonitis, and other inflammations 
of serous membranes, and in septic infections secondary to other diseases. 
It is a frequent cause of secondary inflammations in the lungs, serous 
membranes, and other parts, and of general septicaemia in diphtheria, 
tuberculosis, scarlet fever, typhoid fever, and other infectious fevers, and 
also in many non-infectious diseases. The source of these various second- 
ary streptococcus infections is often from the mouth, tonsils, throat, and 
intestine, parts which in their normal condition often harbor streptococci. 

Of other bacteria more or less frequently present on exposed surfaces 
in health, and concerned in various surgical infections, may be especially 
mentioned the staphylococcus aureus and albus, the micrococcus lanceo- 
latus, the bacillus pyocyaneus, the micrococcus tetragenus, bacillus pro- 
teus, and the bacillus of Friedliinder. 

External Sources. — Bacteria derived from without the body are 
those chiefly concerned in infections of wounds and most other primary 
surgical infections. Abundant experience has demonstrated that if all 
pathogenic bacteria from external sources, as well as those which may 
happen to be upon the surface of the skin, be kept out of an external 
wound, no suppuration of the wound occurs. 

There are two ways by which external bacteria may enter a wound : 
one is by contact with objects contaminated with bacteria ; the other is 
by the air. Strictly speaking, air infection is also contact infection, but 
the distinction implied in the customary use of these terms is a useful 
one. Experimental and clinical observations have shown conclusively 
that contact infection is far more dangerous and common than air 
infection. 

The main emphasis of modern surgical technique is laid upon the 
sterilization of all objects, such as instruments, ligatures, dressings, and 
the hands of operator and assistants, which are brought into contact with 
the wound. The principal sources of contact infection of wounds, as 
enumerated by Park,' are the skin and hair, instruments, sponges or 
their substitutes, suture material, the hands of the surgeon and his assist- 
ants, drainag%materials, dressing materials, miscellaneous — e. g. drops 
of perspiration, an unclean irrigator-nozzle, the nail-brush, the clothing 
of the operator or the bystanders, etc. Of these objects the most difficult 
to disinfect is the skin. We have already considered this subject, so far 
as it belongs to this article, in describing the bacteria of the skin. 

The pyogenic cocci, which are the bacteria concerned in the great 
majority of cases of wound-infection, are ubiquitous, and it would be 
useless to attempt to specify all the objects upon which they have been 
found. The source from which these cocci are derived is not, however, 
a matter of indifference. The pyogenic cocci, and particularly the strep- 
tococcus, derived from infected persons, as from a case of erysipelas or 
peritonitis or septicaemia, are more likely to cause serious infection of 
wounds than cocci of the same species derived from other sources. 

Of other bacteria sometimes concerned in wound-infection, the bacillus 
coli communis not only is a constant inhabitant of the normal intestine, 

'Eoswell Park, " Wound-infection," Amerimn Journal of the Medical Scie.nees, Nov., 
1891. 



276 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

but is widely distributed in external nature, and the bacillus pyocya- 
neus, often present on the healthy skin, is likewise a Avidely-dis- 
tributed organism. The bacillus pyocyaneus is a comparatively harm- 
less organism in external wounds, but it is capable of exerting serious 
pathogenic activity, especially in infections from the intestine. The 
soil is the natural home of the tetanus bacillus, which is abundant in 
certain localities and rare in other places. It has been found with 
especial frequency in garden earth and about stables. It is present very 
commonly in the faeces of herbivorous animals, as has already been men- 
tioned. Sormani observed that tetanogenic material introduced into the 
alimentary canal of dogs, which subsequently were prevented from 
receiving additional tetanus bacilli, could be demonstrated as long as 
sixteen days after its reception. The bacillus of malignant cedema is 
likewise a common inhabitant of the soil. In infected localities the 
anthrax bacillus lives in the soil. In fact, the upper layers of the soil 
are the great home of bacteria of all sorts, and pyogenic cocci have 
been found in this situation. The proteus bacillus, which is capable of 
assuming pathogenic activity, is commonly found in decomposing animal 
substances. 

Flies and other insects may be the carriers of all sorts of infectious 
agents. Pyogenic staphylococci have been found in the excrements of 
flies, and even the susceptible cholera bacillus passes unharmed through 
the alimentary canal of flies. 

C'ertain surgical infections are associated particularly with injuries 
from definite objects, as, for example, necrogenic warts, containing tuber- 
cle bacilli, from cadavers ; zoonotic erysipeloid from crabs and other 
shellfish ; oyster-shucker's keratitis ; actinomycosis from oats and other 
grains ; anthrax from hides, wool-sorting, and other handling of material 
from infected animals. 

It has been demonstrated by La Garde ^ that bullets obtained from 
previously unopened boxes as sent out by the manufacturer are practically 
sterile, but that if the bullets become contaminated with pathogenic 
bacteria, the latter are not destroyed in the discharge and transit of the 
bullet, and are capable of infecting wounds. He was able to infect rab- 
bits with the streptococcus pyogenes and other pathogenic bacteria by 
firing infected bullets through the ear. 

As compared with contact infection, infection of wounds from the air 
is of minor importance, but surgeons are not agreed as to whether or not 
the dangers of air infection are so slight under ordinary conditions that 
they need not be taken into consideration at all. In the eai-ly days of 
antiseptic surgery bacteria of the air were thought to be frequent agents 
of wound-infection and the carbolic spray was introduced by Lister with 
the intention of destroying them. There followed a period when sur- 
geons considered that the air bacteria could be wliolly neglected as a 
source of traumatic infection, and this is probably still the opinion of the 
majority of surgeons. At present there is a tendency again to pay more 
attention to the possibilities of infection from this source, and some sur- 
geons have even gone back to the use of the sprav. 

Bacteria are always present in the air over the ground and around 
human habitations, whereas sea-air at a considerable distance from land 
' La Garde, New York Medical Journal, Oct. 22, 1892. 



SOURCES OF THE BACTERIA IN SURGICAL INFECTIONS. 277 

and the air at high altitudes is nearly or quite free from micro-organisms. 
Bacteria do not usually occur in the air as single, detached cells, but 
rather as clumps attached to particles of dust, so that in a perfectly 
quiet atmosphere, as in a closed room, these particles containing bacteria 
rapidly settle upon underlying objects. Bacteria, being tlius attached to 
particles of dust, are readily filtered out from the air by passing it 
through porous substances, such as cotton-wool. The bacteria are car- 
ried clown by drops of rain, and the air of a room may be freed from 
floating bacteria by producing an artificial rain by some form of douche 
or spray apparatus. 

Whatever creates dust, such as the entrance or exit of a body of 
students, and other movements in a room, brings bacteria into the air. 

It is a fact of fundamental hygienic importance that fine particles, 
including bacteria, are not detached from moist surfaces even by strong 
currents of air. Hence comes the hygienic value of using moist cloths 
in removing dust and in cleansing a room. Substances containing 
infected material should not be allowed to dry under conditions in 
which dust therefrom can be conveyed into the air. In the present era 
of dry dressings for Avounds there is frequent opportunity for the scatter- 
ing of dust from the discharges dried on the dressings in the renioval 
and subsequent handling of these dressings, unless especial care be 
taken to prevent this in all cases where pathogenic bacteria may be 
present. 

The number of bacteria in the air varies greatly under different con- 
ditions. In general it may be said that living micro-otganisms are less 
abundant in the air than was formerly supposed. They cannot multiply 
in the air, and only those whose vitality is not destroyed by drying can 
exist in the air. Desiccation may lessen the virulence of pathogenic bac- 
teria without actually destroying them. 

What interests us chiefly in this connection is to know whether patho- 
genic bacteria, and more particularly the pyogenic cocci, occur in the 
air, and, if so, how frequently and under what conditions. 

Pyogenic staphylococci and streptococci have been repeatedly found in 
the air, although generally only in small number. Obtained from this 
source, these cocci are often of only slight virulence, but highly virulent 
staphylococci and streptococci have been isolated from the air. Among 
those who have isolated pyogenic cocci from the air may be especially 
mentioned von Eiselsberg, Emmerich, Neumann, Prudden, Ullmann, 
Haegler, C Fraenkel. Haegler^ demonstrated that streptococci may 
preserve their vitality and power of development for at least thirty- 
six days, and staphylococci for one hundred days, in pus dried on 
bandages. 

Pyogenic staphylococci and streptococci have been found far more 
frequently in hospital wards and operating amphitheati'cs than else- 
where. Haegler found staphylococci and streptococci in the majority 
of his examinations of the air in the wards and operating-rooms of the 
hospital in Basle, and the number of such cocci present was in general 
proportionate to the opportunity for entrance into the air of cocci from 
dry material and to the amount of stirring up of dust by movement in 
the room. He also detected in a number of instances the bacillus pyo- 
' Haegler, Beitrdge zar klinischen Chirurgie, Bd. ix. p. 496. 



278 GENERAL BACTERIOLOOY OF SURGICAL INFECTIONS. 

cyaneus in the air. Streptococci have been found frequently in the air 
of rooms containing cases of erysipelas. 

Haegler found the pyogenic cocci on the hair and coats of surgeons, 
and in cobwebs in hospital rooms, as well as on other objects. He con- 
cludes from his investigations that the danger of infection from the air 
is greater than is assumed by many surgeons. 

Schimmelbusch and some other investigators have found pyogenic 
cocci very rarely in surgical wards and operating-rooms. It is suf- 
ficiently apparent that various circumstances, such as the care exercised 
in the destruction or sterilization of material infected with discharges, 
the use of disinfectants, the isolation of infected cases, and the observ- 
ance of strict cleanliness, must influence the results of these examina- 
tions of the air of hospitals, and that the danger of air infection may be 
considerable in one place and reduced to a minimum in others. 

Air infection may readily become contact infection by bacteria from 
the air being deposited upon the hands of the operator or his assistants, 
upon instruments, dressings, or other objects which are brought into 
contact with the wound. 

Micro-organisms which are capable of development only within the 
living body are called obligatory parasites. A facultative parasite is 
one whose ordinary mode of life is saprophytic, but which is capable 
of a parasitic existence, and a facultative saprophyte is one ^^•hose ordi- 
nary existence is parasitic, but which can grow outside of a living host. 
These distinctions, however, cannot always be sharply carried out in 
practice. Although we can cultivate the gonococcus outside of the body 
in specially prepared artificial media, there is no reason to suppose that 
it multiplies, or even long survives, in the outer world under ordinary 
conditions, and immediate contact with the infected person is the principal 
source of infection. The tubercle bacillus also can be cultivated arti- 
ficially, but conditions must be exceptional which permit its multiplica- 
tion outside of the body. Unlike the gonococcus, the tubercle bacillus 
is capable of pi'olonged survival outside of the body, and, as is well 
known, it is a widely-distributed organism. The leprosy bacillus has 
not been cultivated artificially, and it is ranked among the obligatory 
parasites. Intimate contact with an infected person seems to be the 
usual source of infection, although opinions are divided as to the mode 
of transmission of this disease. Tiie micro-organisms causing syphilis 
and hydrophobia are unknown, but they are doubtless obligatory para- 
sites. 

The bacteria causing anthrax, tetanus, malignant oedema, and actino- 
mycosis are facultative pai'asites. The pyogenic cocci find the best con- 
ditions for their multiplication in the living body or material rich in 
organic matter, but these ubiquitous bacteria can often find natural 
opportunity for multiplication outside of the body. 

The only bacteria infectious for human beings which are positively 
known to develop spores are the bacilli of tetanus, anthrax, and malig- 
nant oedema, all killed by exposure in a moist condition for a few 
minutes to boiling temperature. It is generally stated that the tubercle 
bacillus forms spores, but this is not positively demonstrated. There is 
still greater doubt as to the formation of spores by the bacilli of gland- 
ers, typhoid fever, and leprosy. The tubercle bacillus, the pyogenic 



PORTALS OF ENTRY OF BACTERIA IN SURGICAL INFECTIONS 279 

cocci, and the typhoid bacilhis are among the more resistant bacteria 
which are not proven to form spores. 

Portals op Entry op Bacteria in Surgical Infections. 

The portals of entry or atria of infection are the skin and the 
exposed mucous membranes of the respiratory, alimentary, and genito- 
urinary tract, and wounds of these surfaces. The foetus may become 
infected either by germinal, or far more frequently by placental, trans- 
mission of infectious micro-organisms. In our laboratory experiments 
we rarely imitate the precise conditions of natural infection, but we 
make frequent use of methods of inoculation which occur only excep- 
tionally or not at all under natural conditions, such as the injection of 
bacteria directly into the vessels, into the serous cavities, and beneath 
the skin, and forced inhalations of large numbers of micro-organisms. 

Most of the bacteria concerned in surgical infections are capable of 
entrance through any portal and of producing infection in any part of 
the body, but there are some which are restricted to certain modes of 
entrance and to certain parts of the body. Examples of the latter group 
are the bacteria causing gonorrhcea and tetanus. 

Let us consider briefly the defensive arrangements which exist nor- 
mally at the various portals of entry. These are partly mechanical, and 
due to the anatomical structure of the part. The thick epidermal cover- 
ing of the skin and orifices of the body is impenetrable to most bacteria. 
The thick layer of laminated flat epithelium covering the mucous mem- 
branes of the mouth, oesophagus, and vagina is a hardly less efficnent 
mechanical protection. The more delicate mucous membranes covered 
by cylindrical epithelium are so situated as to be less exposed to injury, 
but even these surfaces do not ordinarily permit the penetration of bac- 
teria without the occurrence of some damage to their integrity. The 
ciliated epithelium of the respiratory tract drives foreign particles 
toward the natural outlets. The tortuous arrangement of the upper 
air-passages filters out most of the bacteria which are inhaled. Bacteria 
which may happen to enter the bladder or uterus or the glandular ducts, 
such as the salivary, biliary, or pancreatic, which are normally free from 
bacteria, would be likely to be discharged with the secretions. Obstruc- 
tion of these ducts predisposes to their infection. 

There are certain situations, particularly the tonsils and the lymphatic 
follicles of the intestine, which, by the delicate nature of their covering, 
are especially exposed to the invasion of bacteria. These are vulnerable 
parts, as is shown by the frequency with which primary and secondary 
infections start from them, but there is reason to believe that the lym- 
phatic tissue in these situations is richly endowed with vital properties 
hostile to the development of bacteria. 

Of equal importance with these mechanical defences are the anti- 
bacterial properties of the secretions on mucous membranes. These 
properties depend partly on the chemical reaction (gastric juice, vaginal 
secretion), partly on the antagonism offered to invaders by the regular 
bacterial flora of the surface, but mainly upon bactericidal qualities at 
present little understood as to their cause, but unquestionable as to their 
existence. 



280 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

Micro-organisms find at the gates of entrance living cells and fluids 
which in health are capable of destroying many of them, and if they 
pass these gates, it is usually only to be arrested and destroyed at the 
nearest lymphatic glands. Nor are these protective agencies limited to 
the lymphatics or to any particular organs : they are present in the blood 
and everywhere throughout the living body, although more highly devel- 
oped in some places than in others. Whether the battle against the 
invaders be within the cells, as is assumed in the phagocytic theory, or 
outside of the cells, the weapons of attack must be furnished by the 
cells. The living body is amply protected in health against all ordinary 
bacteria which iiiay seek entrance, and the study of the etiology of infec- 
tious diseases involves the consideration not only of the characters of the 
specific agents of infection, but also of the ways in which the natural 
defences of the body have been overcome. There are infectious micro- 
organisms to which the healthiest and strongest body is able to offer no 
resistance, and there are other micro-organisms which are capable of 
doing harm only M-hen the vital resistance of the body has been lowered. 

Can micro-organisms penetrate the intact skin or mucous membranes, 
or must there always be some pathological change or lesion of continuity 
of these parts to permit their entrance ? This question has been variously 
answered, but, at least as far as certain membranes and certain micro- 
organisms are concerned, the evidence must be regarded as conclusive 
for the affirmative answer. It cannot be doubted that the infectious 
agents causing malaria, relapsing fever, and the eruptive fevers may 
enter the body without any defect in the skin or mucous membranes, 
but our concern is not with this class of diseases. 

Garr6,^ in 1885, was the first to make a self-sacrificing experiment 
which has since been repeated with similar result by several others. He 
rubbed into the skin of his forearm, in the same way as one would rub 
in an ointment, a large quantity of a virulent culture of the staphylo- 
coccus pyogenes aureus. The skin was left intact. After six hours a 
prickling sensation, associated with redness and turgescence, developed, 
and in a few hours more about twenty pustules, each developing about 
a lanugo hair, had formed. In the course of four days an extensive 
carbuncle, which discharged pus through seventeen openings, formed, 
and the axillary glands were swollen. 

The largest number of experiments of this character have been by 
"Wasmuth.^ The experiment succeeds almost invariably when virulent 
staphylococci are thoroughly rubbed into the human skin, but fails 
almost constantly to give a positive result upon the skin of animals 
(rabbits, guinea-pigs). The failure with animals is not due to greater 
impenetrability of their skin to bacteria, for anthrax bacilli and some 
other pathogenic bacteria when rubbed into the skin of animals are 
capable of causing infection. Animals are less susceptible than man to 
these pyogenic cocci — a fact which should not be lost sight of in dra^^■- 
ing inferences applicable to man from experiments upon animals Avith 
these organisms. Biidinger has shown that pyogenic cocci nearlv devoid 
of virulence for animals may produce abscesses when rubbed "into the 
human skin. 

' Garri5, Forltchntte der Median, Bd. iii. p. 165, 1885. 

^ Wasmuth, Centralblail fur Bacteriologie, Bd. xii. pp. 824 and 846 1892. 



PORTALS OF ENTRY OF BACTERIA IN SURGICAL INFECTIONS 281 

The mere application of tlie bacteria to the surface of the skin pro- 
duces no infection either in man or animals. The bacteria must be well 
rubbed in or pressed in to cause infection. 

Through what channels do the bacteria penetrate the skin in these 
experiments? There are three possibilities — namely, through the epi- 
dermis into the rete Malpighii, into the sweat-glands, or into the hair- 
follicles and sebaceous glands. Schimmelbusch, Machnoff, and VVasmuth 
have demonstrated that they enter by way of the hair-follicles, and the 
last-named author considers that they can enter the intact skin in no 
other way. He finds a principal support for this view in the fact that 
he was unable to produce any effect by rubbing the cultures into the skin 
of the ball of the thumb, where there are no hair-follicles, and in the 
actual demonstration by himself and previous experimenters of the bac- 
teria in the hair-follicles. This conclusion is in accord with the clinical 
fact that furuncles form almost exclusively in parts of the skin provided 
with hairs and sebaceous glands, and often begin as pustules around the 
hairs. 

The objection may be raised that these experiments do not actually 
prove the possibility of infectious agents peneti'ating the intact skin, as 
microscopical lesions may be caused by the rubbing or the pressure. 
Macroscopical and microscopical examinations, however, failed to show 
any lesion of the epidermis. Still, a microscopical defect might be diffi- 
cult to detect, and Schimmelbusch considers it possible that in these 
experiments a minute breach of continuity may be produced. 

As experiments upon rabbits with bacilli of anthrax and of rabbit 
septicaemia have shown, general as well as local infection may follow the 
rubbing of certain pathogenic bacteria into the skin. These experiments 
simply show that certain pathogenic organisms are capable of settling in 
the healthy skin and causing local infections, which may, however, be 
the starting-point of general infections. They do not show that micro- 
organisms can pass through the health)' skin and thence invade the body 
without producing any damage at the point of entrance. It is a well- 
known clinical fact that in wounds this local damage may be very slight 
and readily overlooked. Indeed, there is a certain antagonism between 
the extent of the local infection at the point of invasion and the likeli- 
hood of general infection. 

We have no conclusive experimental evidence that bacteria can enter 
the circulation through an intact mucous membrane without causing any 
lesion whatever at their point of entry. There are, however, many ex- 
amples of pathogenic bacteria which are capable of attacking a healthy 
mucous membrane and of producing local and general infection through 
this channel. The lesion of the mucous membrane in some of these cases 
may be slight and not readily demonstrable. The gonococcus is certainly 
capable of infecting an intact mucous membrane. A large number of 
infectious diseases can be produced by feeding cultures or material con- 
taining certain pathogenic bacteria. Examples of such intestinal infec- 
tions are tuberculosis, anthrax, typhoid fever, Asiatic cholera, hog cholera, 
and chicken cholera. As has already been mentioned, the points in the 
alimentary canal most vulnerable to infection are the tonsils and the 
lymphatic follicles. 

As is well known, indifferent foreign particles, such as coal-dust, may 



282 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

be taken up from the air-cells of the lungs and conveyed by the lymphatic 
current to the bronchial lymphatic glands, but under normal conditions 
these particles do not enter the general circulation. It is probable that 
bacteria may be disposed of in the same way. It is said that some of the 
bacteria of the se])tic8emias of animals — as, for example, the bacillus of 
rabbit septicsemia — may enter the circulation through the lungs without 
leaving behind any manifest lesion. We have no conclusive evidence 
that the micrococcus lanceolatus, the streptococcus pyogenes, or the other 
pyogenic bacteria can pass through the intact lungs into the general cir- 
culation without causing some inflammation of the lungs. 

The lungs possess the power of disposing of many pathogenic bacteria 
which have been introduced into them. There have been many experi- 
ments made to determine the possibility of infection with anthrax bacilli 
by way of the lungs, and the conclusions drawn from them have been 
widely divergent. Buchner and his pupils claim to have succeeded, but 
Baumgarten and his co-workers reached a different conclusion. Gramat- 
schikoff finds that the intratracheal injection of anthrax bacilli or spores 
is incapable of causing infection if infection through the wound be 
avoided. The bacilli quickly perished in the lungs, sections showing 
degenerated bacilli within four to ten hours. 

No infection of an intact mucous membrane, either in man or animals, 
has been produced experimentally by the mere application to the surface 
of the membrane of the pyogenic cocci, although there is clinical evidence 
of the possibility of such a mode of infection. 

The chief surgical interest of the question of the permeability of intact 
mucous membranes to bacteria relates to the explanation of tuberculosis 
of internal parts without tubercular lesion at any portal of entrv, and to 
cases of osteomyelitis, internal abscesses, and, in general, the cases of so- 
called cryptogenetic septicsemia and pyaemia, in which the most careful 
examination fails to detect any point where the bacteria could have 
entered. 

Most authorities are of the opinion that tubercle bacilli can pass 
through a mucous surface without leaving any trace behind of their 
presence at the point of entrance. The main support for this doctrine 
of the passage of tubercle bacilli through intact mucous membranes is 
found in the clinical facts. Orth and Wesener, however, claim that 
occasionally animals fed with tubercle bacilli develop tuberculosis of the 
mesenteric glands without any tubercular alteration of the intestinal mu- 
cous membrane. Baumgarten contests this, and holds that in all cases 
of experimental tuberculosis there is a tuberculous lesion at the point of 
entry. He explains the cases of tuberculosis of lymphatic glands, of 
bone, and of other parts observed not infrequently in man without 
tuberculosis of the lui%s or any exposed surface by assuming that they 
are all instances of inheritance of tubercle bacilli. This well-known 
doctrine of Baumgarten involves also the assumption that tubercle bacilli 
may remain for an indefinite time alive within the body in a latent con- 
dition. 

In the opinion of the writer the evidence is in favor of the view that 
tubercle bacilli may enter the lymphatic circulation without causing any 
tuberculous affection at the point of entrance. In many cases, however, 
where this explanation might at first be thought to be the correct one, 



PORTALS OF E^^TRY OF BACTERIA IN SURGICAL INFECTIONS. 283 

careful search will reveal the atrium morbi, not infrequently in the 
form of a small healed tuberculous focus in the lungs or other exposed 
part. H. P. Loomis has found tubercle bacilli in the bronchial glands 
without tuberculous lesion in any part of the body. 

It is not possible at present either to prove or to disprove, for man, 
the possibility of the passage through an intact mucous membrane of 
the pyogenic cocci, which are the organisms usually concerned in the 
so-called cryptogenetic jDyssmic and septic processes. It is true that the 
most careful examination in many of these cases fails to reveal the atrium 
of infection, but who can say that it may not have been overlooked ? 
The more painstaking the search, the more likely is some portal of entry 
to be found. This portal may be the root of a carious tooth, the middle 
ear, one of the nasal sinuses, or some other part not usually examined 
at autopsies. Who can feel sure that in the whole vast extent of the 
alimentary, respiratory, or genito-urinary mucous membranes some 
minute lesion, serving as a point of entry, does not exist ? Such a lesion 
may be microscopic in size, perhaps no more than a necrotic epithelial 
cell. Moreover, we have to consider that the original lesion at the point 
of entry may have healed without leaving any recognizable trace ; nor 
need this lesion be a recent one. There are instances of fatal septicemia 
following, mere punctures and scratches of the skin which gave rise to 
scarcely any local inflammation, and the septicsemia may develop after 
the point of original injury has healed and been forgotten. Bacteria, 
including pathogenic species, may remain alive, but quiescent, for weeks 
and months, in some instances it would seem even for years, within the 
body, and then, as the result of a trauma or some other cause, their 
pathogenic energies may be stimulated into activity. 

While it is certain that in many instances pathogenic micro-organisms 
may invade an intact mucous membrane and cause local and general 
infection, and that in some instances the organism may enter the circula- 
tion and be transported to distant parts without manifest lesion at the 
point of entrance, and while the possibility of the latter occurrence can- 
not be disproven in the case of the pyogenic cocci, nevertheless there 
can be no doubt that pathological alterations and wounds of the exposed 
surfaces of the body open the way for the entrance of the pathogenic 
micro-organisms in most surgical infections. For some pathogenic organ- 
isms, including jwogenic cocci of exalted virulence — such as may come 
from a case of puerperal peritonitis, for example — all that is needed is 
that the parts should be thus opened, and infection is sure to follow their 
entrance. But we have only to contrast the frequency with which 
streptococcus and other pyogenic infections complicate or follow the 
infectious fevers, such as typhoid, characterized by lesions of mucous 
membranes, or the frequency with which infection follows external 
wounds in diabetic and dropsical persons, with the rarity of such a sequel 
to injuries of the same parts in a healthy person, to appreciate the 
importance of other factors than the mere breach of continuity in an 
exposed surface in predisposing to local and general infections. We 
shall consider later these local and predisposing causes of surgical 
infections. 

Interesting experiments have been made by Schimmelbusch, Nissen, 
Pfuhl, and others as to the rapidity of absorption of bacteria from fresh 



284 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

wouads. They have demonstrated that bacteria are taken up within 
a very short time, by the lymphatic and blood-vessels, from a fresh 
bleeding wound. Mice inoculated with anthrax bacilli at the tip of 
the tail died of anthrax in spite of amputation of the tail ten minutes 
after the inoculation. Nissen found anthrax bacilli in the nearest lym- 
phatic glands Avithin one hour and a half after peripheral inoculation 
of an extremity. The application to smooth fresh wounds by Schim- 
melbusch of a moderate quantity of a culture of the anthrax bacillus 
or of a streptococcus lethal to mice was fatal, notwithstanding an imme- 
diate attempt at disinfection of the wound with the strongest antiseptics. 
Schimmelbusch and Ricker' were able to demonstrate in cultures from 
the internal organs (lung, liver, spleen, kidney) anthrax bacilli in an 
hour, or even half an hour, after the inoculation of fresh wounds of 
mice with this organism. They showed that this rapid absorption of 
bacteria from fresh bleeding wounds applies equally to pathogenic and 
saprophytic bacteria. In cultures from the internal organs made five 
minutes after the infection of a fresh wound of a rabbit's thigh with the 
bacillus pyocyaneus they found many colonies of this bacillus. In 
making the cultures it is necessary to use the whole organ finely 
divided. 

The significance for the individual of the rapid absorption of bacteria 
from fresh wounds depends, of course, primarily, upon the character of 
the bacteria. If these in small or moderate number are capable of 
causing fatal septicsemia, as is the case with virulent anthrax bacilli in 
highly susceptible animals, the issue is necessarily fatal ; if, as is the 
case with the pyogenic cocci, the bacteria do not readily gain a foothold 
where they can multiply, their absorption is of little consequence in 
most cases, and, so far as the ordinary saprophytes are concerned, their 
absorption from fresh A\-ounds is a matter of indifference. 

The period during which this rapid absorption of bacteria from 
a fresh wound takes place is of short duration. As soon as a coagulum 
has formed on the surface of the wound and the open mouths of the 
lymphatic and blood-vessels are plugged, the conditions are changed, 
and fine particles like bacteria are no longer quickly transported into the 
lymphatic and blood circulation. The surface of a healthy granulating 
wound offers great resistance to the invasion of bacteria, almost as much 
as an intact exposed surface of the body. Slight injuries, however, such 
as probing, the removal of dressings, and other manipulations, ma}' con- 
vert a granulating surface into a fresh wound, with the accompanying 
dangers of infection. 

Elimination of Bacteria in the Secretions. 

In former times it was thought that the body gets rid of infectious 
agents chiefly by their excretion through the emunctory channels. AVe 
now know that micro-organisms are destroyed within the body by the 
living cells and fluids, and that this method of freeing the body from 
living bacteria is far more efficient and of much greater importance than 
that of their excretion by the emunctories. 

Pathogenic bacteria often appear in the secretions in various infectious 
' Schimmelbusch, Deutsche med. Wochenschrift, July 12, 1894. 



ELIMINATION OF BACTERIA IN THE SECRETIONS. 285 

diseases, and it is of interest to itnow under what conditions they are 
excreted and in what secretions they occur. The mode of conveyance 
of infectious organisms from an infected individual to others, and the 
practical measures of prevention, are determined in large measure by the 
manner of elimination of these organisms from the infected body. 

AA^yssokowitsch, as the result of a long series of experiments, came to 
the conclusion that bacteria in the circulation are never discharged from 
the body through the healthy organs, but escape only through some 
breach of continuity or other lesion in the excretory membrane. Hence 
those pathogenic bacteria which cause some damage to the excretory 
surfaces — and there are many such bacteria — are most likely to appear in 
the excreta, although bacteria without this capacity may escape through 
lesions preformed from other causes. 

Not all subsequent investigators of this subject have been able to con- 
firm this law of VVyssokowitsch, and it is true that bacteria may be elimi- 
nated from the circulation by way of the excretions without demonstrable 
lesion of the organ through which they have passed. It is to be remem- 
bered, however, that the lesion may be difficult to detect, or may be of 
some such undemonstrable character as that of the vascular walls in 
inflammation which permits the passage of leucocytes and red blood- 
corpuscles. 

There have been many special and incidental investigations of the 
subject of the escape of bacteria with the secretions. Of the experimental 
investigations relating to the subject in general the most important are 
those of Wyssokowitsch, Pernice and Scagliosi, and Sherrington.' 

Sherrington experimented on mice, rabbits, and guinea-pigs by the 
subcutaneous or intravenous inoculation of eleven, mostly pathogenic, 
species of bacteria. In sixty-eight observations the presence of the 
specific micro-organism introduced was detected in the urine twenty- 
one times ; on eight of these twenty-one occasions the presence of blood 
in the urine was ascertained by the spectroscope ; and in a ninth case 
gross lesions (tubercle) were found in the kidney. Sometimes the urine 
contained much coagulable albumin. Of the bacteria of surgical im- 
portance tested, the staphylococcus aureus, the bacillus pyocyaneus, the 
bacillus anthracis, and a bacillus probably identical with the Friedliinder 
bacillus were found frequently in the urine. In forty-nine experiments 
the specific bacilli were found in the bile in eighteen. The bacillus of 
mouse septicfemia appeared in the conjunctiva, which became inflamed, 
under conditions making it probable that it did not enter from without. 
Among the points especially emphasized by Sherrington are the fol- 
lowing : 

" At a time when every drop of the circulating blood is teeming with 
micro-organisms there may not be the slightest transit of them into the 
urinary and biliary fluids then secreted, and they may be completely 
absent from the aqueous humor of the eye-ball." 

" When certain pathogenic species are employed, a number, often 
very considerable, of the injected bacteria tend after a time to appear in 
the secretions of the kidney and liver, and their escape in the secreta is 

' Sherrington, " Experiments on the Escape of Bacteria with the Secretions," The 
Journal of Pathology and Bacteriology, Feb., 1893. This valuable article contains a full 
review of the literature. 



286 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

sometimes accompanied by an escape of actual blood," although not infre- 
quently there is no blood in the secreta. 

" The evidence is against believing that when this transit of bacteria 
across the secreting membrane occurs the membrane is still normal in 
condition, although at the same time it need not be ruptured or pervious 
to red blood-corpuscles." 

" The fact that the escape of the bacteria tends to occur, not immedi- 
ately upon the introduction of them wholesale into the circulation, but 
in the late stages of the communicated disease, suggests that the healthy 
secreting membranes are not pervious to bacteria, and that only after 
soluble poisons produced by the infection have had time to act upon 
them do the membranes became pervious to the germs. The fact that 
species which are innocuous did not in the experiments appear in the 
secreta at any time is in conformity with this conclusion." 

Pernice and Scagliosi experimented with staphylococcus aureus, 
bacillus prodigiosus, bacillus anthracis, bacillus pyocyaneus, and bacillus 
subtilis, and they found that these bacteria were constantly excreted 
through the urine and bile, and might escape through various mucous 
membranes. This excretion begins six to eight hours after their intro- 
duction. Virulent bacteria retain their virulence, as a rule, in the 
excreta. 

There are numerous observations in human beings of the escape of 
infectious bacteria through the excretions. The pyogenic cocci are par- 
ticularly prone to settle in the kidney and cause focal inflammations, but 
even ^vithout actual foci of suppuration they often escape into the urine. 
Nannotti and Baciochi, both in grave suppurative processes and in slight 
ones, found the specific bacteria with great frequency and of customary 
virulence in the urine. They disappeared from the urine twenty-four to 
thirty-six hours after the evacuation of the pus. In experimental pyo- 
cyaneus infections the specific bacillus is found regularly in the urine. 
The micrococcus lanceolatus in pneumonia and other pneumococcus 
infections, the typhoid bacillus in typhoid fever, the streptococci in 
erysipelas and other streptococcus infections, are often present in the 
urine. The bacillus coli communis, the most common of all secondary 
invaders, often escapes through the kidney. 

Pathogenic bacteria are eliminated Aery often through the bile. One 
of the most common lesions in various infectious diseases is the presence 
of focal necroses, sometimes visible to the naked eye and sometimes seen 
only with the microscope, in the liver, and these permit the passage of 
bacteria into the bile. It is not, however, necessary that such necroses 
should be present in order to permit the escape of bacteria into the 
bile. 

Blachstein, in experiments made under the direction of the writer, 
demonstrated that the cf)lon bacillus and the typhoid bacillus injected 
into the veins of rabbits often appeared in the bile, where they frequently 
remained alive and in large number weeks and months after they had 
disappeared from all of the internal organs. In many of these "cases 
there were focal necroses in the liver. The passage from the circulation 
into the bile of the anthrax bacillus, of the micrococcus lanceolatus, the 
streptococcus pyogenes, the pyogenic staphylococci, the bacillus pyocya- 
neus, and of other bacteria has been repeatedly demonstrated. Patho- 



ELIMINATION OF BACTERIA IN THE SECRETIONS. 287 

genie bacteria are quite as frequently discharged through the bile as 
through the urine. 

Of course bacteria in the bile will enter the intestine with this secre- 
tion, and it is therefore not always easy to determine whether specific 
pathogenic bacteria found in the intestine in infectious diseases have 
been discharged through the waW of the intestine or through the li\'er. 
Most of the observations recorded concerning the transit of bacteria 
through the intestinal wall from the circulation have not been made so 
as to determine whether or not the escape is really through the intestinal 
mucosa or by way of the bile. Nevertheless, the frequency with which 
hemorrhages, necroses, inflammations, and ulcers of the intestinal mucous 
membrane occur in various infectious diseases makes it highly probable 
that pathogenic bacteria may be eliminated through this channel. Cer- 
tain it is that the specific infectious bacteria, not only of diseases like 
typhoid fever, cholera, and tuberculosis, characterized by definite intes- 
tinal lesions, but of many other diseases, such as croupous pneumonia, 
septicaemia, pyjemia, are often found in the faeces. 

Tubercle bacilli may be present in the milk of tuberculous cows even 
when there is no demonstrable tuberculosis of the udder. The state- 
ments as to the frequency of this occurrence vary. Ernst demonstrated 
by the microscope tubercle bacilli in the milk of 28.5 per cent, of the 
thirty-five tuberculous cows examined, and by inoculation experiments 
in 50 per cent, of fourteen cows. Bang by the inoculation test found 
tubercle bacilli in the milk of only nine out of sixty-three tuberculous 
cows without mammary tuberculosis. When the udder is tuberculous 
the bacilli are always in the milk. 

Numerous observations have been made to determine whether or not 
the pyogenic cocci are excreted with the milk in puerperal infections, 
but since we now know that the staphylococcus albus is regularly, and 
the staphylococcus aureus is sometimes, present in the milk of healthy 
women, the demonstration of these cocci in the milk in cases of puer- 
peral fever has lost much of its diagnostic significance. There is, 
however, reason to believe that, although the ordinary source of the 
stapliylococci found in the milk is from the skin, they may be excreted 
through the gland from the blood in pyogenic infections. The 
presence of streptococci in the milk is more significant of such ex- 
cretion than that of staphylococci. In several cases of puerperal 
fever streptococci have been found in the milk, although more fre- 
quently they are missed in this secretion under these circumstances. 
There is evidence that the pyogenic cocci causing mastitis may enter 
either from without through the lacteal ducts or may have been depos- 
ited from the circulating blood. Karlinski claims to have demonstrated 
that the staphylococcus aureus injected into the blood of rabbits may be 
excreted through the mammary gland. 

FoS, and Bordoni-Uffreduzzi and Bozzolo have found pneumococci in 
the milk of pregnant women affected with lobar pneumonia, and the 
former investigators demonstrated their presence in the milk of preg- 
nant rabbits inoculated with this organism, and noted pneumococcus 
septicaemia in young rabbits which sucked the breast of their infected 
mothers. 

The typhoid bacillus has been found exceptionally in the milk in cases 



288 GENERAL BACTEBIOLOOY OF SURGICAL INFECTIONS. 

of typhoid fever. In experimental anthrax the specific bacillus appears 
in the milk only exceptionally. 

Brunner found the staphylococcus albus, von Eiselsberg, Preto, and 
Tizzoni the staphylococcus aureus, in the sweat in cases of pysemia. The 
detection of staphylococci, particularly of the staphylococcus albus, in 
the human sweat does not necessarily prove that they have been excreted 
through the sweat-glands from the blood, for even after the most thor- 
ough disinfection of the surface of the skin the white staphylococcus has 
not usually been destroyed in the deeper layers, as has already been 
explained in describing the bacteria of the skin. Still, it is probable 
that pyogenic cocci may be eliminated by the sweat-glands, for Brunner 
has shown that the staphylococcus aureus and the bacillus prodigiosus 
injected into the circulation of swine can be demonstrated in the sweat 
from the snout after administration of pilocarpine. He was also able to 
detect the anthrax bacillus in the sweat from the paw of an infected cat 
after stimulation of the sciatic nerve. He reports only three experiments, 
and it is desirable that more work should be done on this subject, as the 
frequency with which pathogenic bacteria may appear in the sweat in 
infectious diseases is of importance, especially with reference to possibil- 
ities of contagion and to measures of disinfection. 

In Brunner's experiment with the bacillus prodigiosus this organism 
was found also in the saliva, and there are other observations which indi- 
cate the possibility of elimination of bacteria through the salivary glands. 

Conditions favoring the Development op Subgical Infections. 

There are various conditions, relating partly to the micro-organisms 
concerned and partly to the individual receiving the organisms, which 
are determining factors in causing infection. The factors pertaining 
to the individual are usually grouped under the vague but indispensable 
term "predisposition." 

Dosage and Virulence of Infecting Bacteria. — In the case 
of some pathogenic bacteria a single bacterial cell may be capable of 
infecting a highly susceptible animal, whereas with a less susceptible 
animal a large number of the same kind of bacteria may be required. 
In his interesting studies on the relation of the dosage of bacteria to 
infection Watson Cheyne ' showed that whereas a single virulent bacillus 
of rabbit septicEemia was capable of causing fatal septicaemia in the 
highly susceptible rabbit, in the less susceptible guinea-pig the fatal dose 
was 300,000 bacilli and upward ; between 10,000 and 300,000 bacilli 
produced abscesses, and smaller doses were without effect. In a mouse 
a single bacillus of mouse septicsemia, and in a guinea-pig a single viru- 
lent anthrax bacillus, were capable of producing fatal infection, whereas 
in rabbits and sheep a considerable quantity of the anthrax bacilli was 
required to kill the animals. 

Animals are in general insusceptible to small quantities of the pyo- 
genic cocci, whether introduced subcutaneously or into the circulation. It 
generally takes several hundred thousand of the cocci to produce local 
abscesses by intravenous or subcuta,neous injection. Man is more sus- 
ceptible to these cocci. 

' Watson Cheyne, The British Medical Journal, July 31, 1886. 



CONDITIONS FAVORING THE DEVELOPMENT OF INFECTIONS. 289 

_ This question of dosage is largely one of individual or racial suscept- 
ibility on the one hand, and of virulence of the micro-organisms on the 
other hand. 

The kind of infection produced by some bacteria varies with the 
dose. It often happens that the inoculation of a very small number of 
certain pathogenic bacteria produces no effect, a larger number cause only 
a local abscess, and a still larger number cause fatal septicaemia. This is 
illustrated by the micrococcus lanceolatus, some varieties of the strepto- 
coccus pyogenes, and other pyogenic cocci. 

We are familiar with varying degrees of virulence in the case of a 
large number of pathogenic bacteria. Influences known to be capable 
of affecting the vitality and the virulence of bacteria, such as sunlight, 
desiccation, saprophytic growth, association with other bacteria or their 
products, are widely operative in nature. The virulence of a micro- 
organism depends probably mainly upon its capacity to form toxic 
products, as it is by these products that bacteria chiefly produce their 
pathogenic effects. 

Bacteria which enter the body associated with their toxic products 
are much better adapted to cause infection than when they enter deprived 
of these products. These toxic substances, by damaging immediately the 
cells and fluids which protect the body from infection, enable the invader 
to gain a foothold which it might otherwise not have secured. Vaillard 
claims that tetanus spores, deprived by heat or by washing of their 
toxines, are incapable of germinating in the animal body without the 
aid of accessory causes, such as the presence of other micro-organisms, 
dirt, other foreign substances, necrotic tissue, although the spores them- 
selves are still alive and in suitable media capable of dexelopment. If, 
however, as is usual in our laboratory experiments, the spores or bacilli 
be inoculated with the toxin, which in most minute doses is of appalling 
potency, tetanus is sure to develop. In fact, our experimental tetanus 
is, as a rule, essentially a pure intoxication. 

The varying results which follow the introduction into the body of 
pyogenic cocci derived from different sources depend doubtless in part 
upon whether these cocci enter the tissues already equipped with a 
reserve force of poisonous products or must begin the fight unarmed. 
The inoculation of infectious material coming directly from the human 
body, as from a case of puerperal peritonitis, and received perhaps only 
in a puncture or scratch of the skin, may manifest disastrous effects with 
which we are not familiar in inoculations with our artificial cultures of 
the pyogenic cocci obtained from the same source. 

The micrococcus lanceolatus, the streptococcus pyogenes, and the 
pyogenic staphylococci are notable for the wide variations of their 
virulence. The lanceolate coccus quickly loses its virulence in artificial 
cultures. 

The writer has reported observations as to the varying virulence of 
the staphylococcus aureus cultivated from different sources. Some broth 
cultures were fatal to rabbits within twenty-four to forty-eight hours 
when injected into the circulation in the dose of 0.1 c.c, and other 
cultures injected in the same way produced no apparent effect in the 
dose of 1.5 c.c. Between these extremes were cultures of all degrees of 
intermediate virulence. In the majority of cases 0.2 to 0.3 c.c. of fresh 

Vor,. I.— 19 



290 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

bouillon cultures killed the animal within three to seven days after 
intravenous Injection. The variations in virulence of the strejitococcus 
pyogenes are even more striking. Pathogenic bacteria, especially pyo- 
genic cocci, obtained from an infected individual are more likely to be 
highly virulent than when cultivated from other sources. There are, 
however, many exceptions to this general rule. 

In various ways the weakened virulence of pathogenic bacteria may 
become augmented. Among the most important of those ways with 
which we are acquainted are repeated passage through the animal body, 
association with other bacteria or their products, and the addition of cer- 
tain chemical substances. 

The character of the infection varies often with the degree of viru- 
lence of the specific micro-organism. Bacterial species, which when highly 
virulent may kill quickly with septicaemia, may, with weakened viru- 
lence, require a much longer period to produce the same effects, or may 
give rise to only local inflammation without general infection. It is 
especially with bacteria of attenuated virulence that the matter of 
dosage may be a controlling factor. 

The varying virulence of the pyogenic cocci is one of the factors in 
the explanation of the remarkably diverse effects which these organisms 
are capable of producing in the animal body. These cocci may under 
different circumstances cause all grades and kinds of inflammation, serous, 
fibrinous, suppurative ; they may cause localized inflammations and gen- 
eral infections. But there are other circumstances besides the degree of 
virulence which control these varying results. Equally important, in 
many cases more important, controlling factors are the manner of inva- 
sion of the micro-organism and various local and general predisposing 
conditions. 

In fact, there is no definite and constant relation between the charac- 
ter and the severity of an infection produced in man by pyogenic cocci 
and the virulence of the cocci cultivated from the case. From the 
gravest septicsemias cocci of slight degrees of virulence may be culti- 
vated, and from a simple epidermal pustule cocci of high virulence, as 
tested upon animals. There is reason to believe that the virulence of 
the micro-organisms may be modified during the course of an infection, 
so that we cannot necessarily draw conclusions as to the primary viru- 
lence of the organism at the time of its invasion from the virulence 
noted in cultures from later stages of the disease. 

Bacterial Association. — Bacteria are not usually found in the 
external world under natural conditions in pure culture, but they are 
mixed together. Mixed infections are common in human beings. In 
suppurating wounds we usually find more than one bacterial species. It 
is of importance to learn the relations of these bacterial associations to 
infection. We are at present only imperfectly informed as to these rela- 
tions, but we know that they are often of great significance. Only the 
more salient points which directly bear upon our theme can be con- 
sidered here. 

The association of one bacterial species with another may be without 
influence upon the development or the properties of either, or one species 
may be favorable to the growth or enhance the virulence of another, or 
one species may be antagonistic to another or in various ways modify its 



CONDITIOyS FAVORING THE DEVELOPMENT OF INFECTIONS. 291 

characters. Bacteria exert their influence on eacli other in lai'ge part 
through their chemical products, and it is often possible to Ijring about 
modifications of character by exposing one species to the action of the 
chemical products of another species. 

The pathogenic, the chromogenio, the fermentative, and the other 
vital manifestations of bacteria may be influenced by their combination 
with each other. The bacillus pyocyaneus may lose its power of pro- 
ducing pigment when combined Avith certain other bacteria (Miihsam 
and Schimmelbusch). In mixed cultures of certain bacteria chemical 
products may be formed and fermentations produced which neither of 
the species in the culture is capable of producing by itself alone (N^encki, 
Burri, and Stutzer). In mixed cultures of two pathogenic bacteria a 
larger amount of the toxic products of one or both may be formed than 
either produces when in pure culture (von Schreider). 

The effects following the concurrent inoculation of two kinds of 
bacteria vary. The association may be without influence as regards 
infection. The result may be that the development of a deadly species 
of bacterium is checked by the introduction of another species which is 
relatively harmless. The only striking instance of this is the effect of 
the inoculation of the streptococcus of erysipelas, the bacillus of Fried- 
lander, and of several other species of bacteria simultaneously with or 
shortly before or after inoculation with the anthrax bacillus. These 
bacteria or their products introduced into the body are capable of pre- 
venting the developing of the anthrax bacillus and of rescuing the 
animal from certain death (Emmerich and others). Various explana- 
tions of this effect are given by different writers. The effect is prob- 
ably referable not so much to a direct antagonism of one species to the 
other as to an augmentation of the antibacterial properties of the cells, 
which, according to von Dungern and Metschnikoflf, is manifested by 
increased phagocytic activity of the leucocytes. Bacteria in general 
which cause suppuration may thereby prevent the development of the 
anthrax bacillus in the focus of suppuration. 

More frequently the concurrent inoculation of two species of bacteria 
increases the danger to- the animal from one or both. A combination 
of two species, each in itself harmless, may prove fatal to the animal 
(Roger). A bacterium of attenuated virulence may become augmented 
in virulence by inoculation in combination with another species which 
need not necessarily be itself pathogenic, or sometimes simply in com- 
bination with the chemical products of another species. The following 
are examples of the exaltation of the virulence or of the pathogenic 
effects of one kind of bacterium by combined inoculation with another 
kind or its products : that of the micrococcus lanceolatus by combination 
with the proteus vulgaris, the anthrax bacillus, or the diphtheria bacillus 
(Monti, Pane, Mtihlmann, Mya) ; the streptococcus pyogenes with the 
proteus vulgaris, bacillus prodigiosus, bacillus coli communis (Klein, 
Monod, and Macaigne) ; the pyogenic staphylococci with the bacillus pro- 
digiosus or its products and other bacterial products (Grawitz and De 
Bary and others) ; the diphtheria bacillus with the streptococcus pyogenes 
or its products (Roux and Yersin and others) ; the typhoid bacillus with 
the streptococcus pyogenes, colon bacillus, and proteus, or their products 
(Vincent, Sanarelli) ; the bacillus coli communis with the typhoid bacil- 



292 GENERAL BACTEBIOLOGY OF SURGICAL INFECTIONS. 

lus and the streptococcus pyogenes (Pisenti and Bianchi-Mariotti) ; the 
bacillus of synaptomatic anthrax with the bacillus prodigiosus (Roger). 
Mention has already been made of the pathological importance of the 
association of the tetanus bacillus with other bacteria. Of especial 
interest are the experiments of Prudden demonstrating that the intra- 
tracheal injection of cultures of the streptococcus pyogenes in tuber- 
culous rabbits leads to the formation of regular phthisical cavities in the 
lungs — a result which is not obtained by the inoculation of either micro- 
organism alone. Bernheim has demonstrated that the diphtheria bacillus 
grows more luxuriantly and with a larger production of toxin in the 
filtrate of streptococcus bouillon cultures than in ordinary bouillon. 

A most important group of infections, many of them of surgical 
importance, is furnished by the secondary invasion of pathogenic bacteria 
in the course of various infectious diseases, such as typhoid fever, tuber- 
culosis, diphtheria, scarlet fever, small-pox, and other exanthematous 
fevers. The streptococcus pyogenes is more frequently the infectious 
agent in these secondary infections than any other organism, but the 
other pyogenic cocci are not uncommonly concerned. The primary 
infection increases susceptibility to these common pyogenic cocci, which 
often find the way open for their invasion by some lesion of an exposed 
surface of the body. It is also very probable that the primary infection 
may bring about conditions which enhance the virulence of the bacteria 
concerned in the secondary infection. Although it is not necessary to 
suppose that these common secondary invaders are always derived from 
those which are present in health upon exposed mucous membranes, 
nevertheless they doubtless often have this origin. Pyogenic cocci 
obtained from these secondary infections are usually, although by no 
means always, more virulent than when cultivated from the healthy 
mucous membranes. 

Of especial frequency and importance among the mixed and second- 
ary infections here in consideration is the association of the tubercle 
bacillus with the streptococcus pyogenes, the typhoid bacillus with 
pyogenic cocci, and the diphtheria bacillus with streptococci. 

The characters of the various mixed infections are probably deter- 
mined less by a direct influence of one bacterial species or its products 
upon another, although this factor appears in some cases to be an import- 
ant one, than by the action exerted by one or both species upon the 
resisting powers of the fluids and cells of the body. 

Immujjity and Peedisposition. — In no class of infectious diseases 
is the influence of predisposition as an etiological factor more apparent 
than in many of the surgical infections. If a wound could be kept 
entirely free from pathogenic bacteria, it would not suppurate, no matter 
how favorable in other respects the local and general conditions for infec- 
tion might be. The occurrence of suppuration in human beings from 
sterile chemical irritants is so exceptional that we need not consider this 
form of suppuration here. It is not, however, possible in all, or even 
in most, cases to keep bacteria ^^holly out of a wound. The examina- 
tion of so-called aseptic wounds shows with great frequency the presence 
of bacteria, and notably of the white skin-coccus, but also sometimes 
of other pyogenic cocci, including the staphylococcus aureus. Although 
the cocci found under these circumstances are usually of weakened viru- 



CONDITIONS FAVORING THE DEVELOPMENT OF INFECTIONS. 293 

lence, nevertheless, as shown by Biidinger and others, they are of some 
virulence, and may be decidedly virulent. The frequency -with which 
pyogenic bacteria enter wounds is by no means expressed by the fre- 
quency with which wounds suppurate. Every surgeon knows that in 
certain persons and in certain conditions of the body a wound is much 
more likely to suppurate than in others, although the same precautions 
are taken to guard against the entrance of micro-organisms. It is there- 
fore a matter of prime importance, no less of practical than of scientific 
interest, to learn, so far as we may, what are the conditions which pre- 
dispose an individual to infection. Unfortunately, wc are at present . 
only imperfectly informed as to many of these conditions. 

Predisposition is of most importance in the etiology of those infec- 
tious diseases which are caused by micro-organisms to which the individ- 
ual or the species is not in the highest degree susceptible. The jjyogenic 
cocci, in general, belong to this group of micro-organisms, although they 
may exist in a condition of such exalted virulence that predisposition 
becomes a factor of no significance. 

The degree of susceiitibility to a specific micro-organism influences 
not only the capacity to acquire the infection, but also the course, 
severity, and character of the infection. In an individual of great 
susceptibility a micro-organism of attenuated virulence may produce 
effects which in a relatively insusceptible person can be accomplished 
only by a highly virulent micro-organism of the same species. 

The astonishing variety of affections which may under different cir- 
cumstances be caused by pyogenic cocci, from a simple epidermal pustule 
to the gravest septicsemia and pysemia, from a serous to a suppurative 
inflammation, are to be explained in part by \'ariations in the local or 
general susceptibility of the individual, although, as already explained, 
other factors, such as the degree of virulence of the organism, the 
manner of invasion, and the number of organisms introduced, are also 
important. We possess abundant experimental evidence of the fact that 
in the relatively insusceptible many pathogenic bacteria remain localized, 
causing inflammation, whereas the same bacteria in the highly susceptible 
invade the blood and internal organs, causing general septicsemia. 

Immunity. — Our comprehension of the nature and importance of 
predisposition as a factor in the causation of infectious diseases has been 
facilitated by the increase of our knowledge concerning the factors upon 
A\'hich immunity from the invasion and multiplication of bacteria depends ; 
but our understanding of the nature of immunity is still most incom- 
plete. It is not necessary for our purposes in this connection to enter 
into a detailed consideration of the various doctrines of immunity, 
important as are the results of recent investigations upon this subject. 
It will suffice to state briefly the more important facts and hypotheses 
so far as they bear upon the question now under consideration.^ 

We distinguish natural or hereditary immunity from acquired immu- 
nity. Immunity may be acquired by recovery from an attack of a specific 
infectious disease, or may be artificially produced by vaccination with 
the specific micro-organism or its products, or by the injection of the 

' The following statements concerning immunity are taken chiefly from the fuller 
article on this subject by the writer in Pepper's Text-Book of the Theory and Practice of 
Medicine by American Teachers, vol. ii., Philadelphia, 1894. 



294 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

blood-serum or other fluids from individuals rendered artificially 
immune. 

It is certain that the various kinds of immunity do not all depend 
upon the same causes. The leading theories of immunity may be 
brought into two classes — one which attributes immunity to the direct 
and active intervention of the living cells of the body, and the other 
which explains immunity by the properties of the extra-cellular fluids. 
In the last analysis these properties of the body fluids must depend 
upon the activities of cells, so that we must have recourse either directly 
or indirectly to cellular functions in any adequate explanation of im- 
munity. 

The leading representative of the cellular theories is the phagocytic 
theory, so elaborately and charmingly developed by Metschnikoif. This 
supposes that immunity depends upon the seizure of invading micro- 
organisms by amoeboid cells, chiefly leucocytes and other mesodermic 
cells, and the subsequent destruction of these organisms in the interior 
of the cells. According to this view the leucocytes are charged with 
the defence of the body and engage in a veritable conflict with the 
parasites. The significance of inflammation, according to Metschnikofi^, 
is to bring the leucocytes to the seat of danger, to which they are attracted 
by the positively chemotactic substances furnished by the micro-organ- 
isms. Immunity is acquired when the phagocytes have gained tolerance 
of the poisons of the specific micro-organism and are no longer repelled 
by them. 

There exists in a very large number of cases unquestionably a paral- 
lelism between phagocytosis and immunity, but the action of phagocytosis 
is by no means always apparent. We know that micro-organisms may 
be destroyed by extra-cellular agencies as well as within the cells, and it 
is a fair question whether the micro-organisms before their reception by 
cells have not already been damaged by these other agencies. It is true 
that Metschnikoif has proven that phagocytes may take up living and 
virulent bacteria, and that these bacteria may degenerate and die in the 
interior of cells, but he has not shown that, as a rule, bacteria when taken 
up by cells have suffered no injury from extra-cellular agencies. We 
possess direct observations which prove that bacteria introduced into the 
body may degenerate and die not only within cells, but also outside of 
them in the humors. 

The humoral theories of natural immunity have been based largely 
upon the demonstration by Nuttall, Buchner, and others of the bacteri- 
cidal properties of the blood and other fluids of the body. Buchner has 
given the name of " alexins," and Hankin that of " defensive proteids," 
to these bactericidal substances. The bactericidal alexins are believed 
by Kossell and Vaughan to be nucleins or nucleinic acid. Their action 
is not exerted equally upon all bacteria, and there is often no parallelism 
between the presence of this bactericidal property in the blood of the 
normal animal and the insusceptibility of the animal to a given micro- 
organism. The important observation has been made, however, that 
as the result of the introduction of certain micro-organisms the body 
fluids may acquire bactericidal properties as regards the organism intro- 
duced. 

The search for the origin of the alexins has led to the view that they 



CONDITIONS FAVORING THE DEVELOPMENT OF INFECTIONS. 295 

are derived directly from the cells, and particularly from the leucocytes. 
This has led to a partial reconciliation bet-ween the phagocytic and the 
most prominent humoral theories of immunity. The leucocytes and 
other cells are, indeed, the defenders of the body against intruding micro- 
organisms. They furnish the alexins, the weapons of attack. Where 
they accumulate the defensive material is concentrated, but it is not 
necessary that the bacteria should be actually incorporated in the body 
of the cells, although the germicidal propei'ties may be more intense 
\\ithin than without the cells. Such is the explanation of natural immu- 
nity now adopted by Buchner and many others. 

There is a kind of acquired immunity which is not known to have a 
parallel in forms of natural immunity. This is the so-called antitoxic 
immunity. Here, as the result of vaccination with the specific micro- 
organism or its products, the blood and fluids of the immunized animal 
have acquired the property of neutralizing the poison formed by the 
specific organism from -which the individual has been immunized. The 
principles of antitoxic immunity have been worked out for the toxic 
infections, tetanus and diphtheria. The same principle doubtless holds 
good for acquired immunity from some other diseases, but for how large 
a number we cannot say. A most important characteristic of this anti- 
toxic immunity is that by successive injections of increasing amounts of 
the poisonous substances into the animal the antitoxic or immunizing 
power of the fluids can be augmented to an astounding degree. It is in 
this way that the antitoxic power of the fluids may be rendered sufficiently 
high to exert curative effects when injected after the reception of the 
specific micro-organism or its products. This so-called serum-therapy 
lias thus far been applied with beneficial results only to cases of tetanus 
and of diphtheria, and, as regards human beings, it is more efficient in 
diphtheria than in tetanus. 

Local Predisposition. — The term " predisposition " is often used 
in a loose sense to designate all sorts of conditions which increase the 
chances of infection, or which augment susceptibility to infection, or 
which influence the localization, duration, character, or severity of infec- 
tions. A name which is used to refer to conditions belonging to such 
different categories, having often nothing in common, is of course objec- 
tionable, but common usage sanctions the term, and there appears to be 
no better one under which to include the various points here to be con- 
sidered. 

We distinguish racial and individual predisjaosition, inherited and 
acquired predisposition, local and general predis])Osition. 

Instances abound of diflPerences in susceptibility to infectious diseases 
between different species of animals, and there are differences also between 
different races of men ; but the most impoi'tant kind of predisposition, 
as regards those surgical infections which we are here considering, is 
individual predisposition. 

This individual predisposition may be either inherited or acquired. 
It may pertain only to one part or to certain parts of the body, or it may 
belong to the body as a whole. We cannot in many instances determine 
whether the predisposition is local or general, and, indeed, it is often 
impossible to draw any sharp dividing-line between local and general 
predisposition. 



296 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

Local predisposition may be limited to one or more of the portals of 
entry for micro-organisms, or it may exist at some point within the body, 
constituting a so-called locus minoris resistentise. 

We shall consider first predisposing causes of infection at the portals 
of entry. We shall have in view under this heading more particularly 
causes which act locally, but it is to be understood that general predis- 
posing factors to be described later may produce local predisposition. 

Under the heading of "Inflammation produced by Bacteria" Dr. 
Councilman in the preceding article has described the influence upon 
pyogenic infections of many local predisposing factors, such as the 
character of the tissue invaded, local anaemia, passive hypersemia, the 
withdrawal of nerve-impulses from a part, rapidity of absorption, the 
introduction of chemical bacterial products, the presence of foreign 
bodies, previous attacks of inflammation ; and the reader is referred to 
Dr. Councilman's article for these points. It has there been made clear 
that any interference with the integrity of the tissues and of the local 
blood- and lymph-circulation is likely to render them more susceptible to 
pyogenic agents, and to influence unfavorably the character and course 
of a subsequent inflammation. Wounds through a thick layer of adipose 
tissue or cicatricial tissue or other poorly-vascularized parts are less able 
to resist the action of pyogenic bacteria than wounds of such vascular 
parts as the face. 

To the predisposing conditions enumerated may be added cedema of 
the tissues. How important this is may be inferred from the frequency 
with which erysipelas and suppuration follow so slight an injury as 
puncture of an oedematous scrotum or leg. Biidinger found, that pyo- 
genic cocci so weakened in virulence as to produce no efi^ect when inoc- 
ulated into the normal ear of a rabbit set up local suppuration when 
inoculated into an ear rendered hypersemic and oedematous by tempo- 
rary application of a rubber band around the root of the ear. 

The withdi'awal of nerve-impulses from a part may increase its lia- 
bility to infection. The factors here concerned are various, the most 
apparent ones being ansssthesia, disturbances in the lymphatic and 
blood circulation, and nutritive changes. The question as to the exist- 
ence of special trophic nerves, the interference M'ith whose function pre- 
disposes the part to infectious inflammations, has been considered by 
Dr. Councilman. In a personal communication Dr. Weir Mitchell has 
kindly favored the writer with the following expression of his views 
on this point : " I think it true that the withdraMal of nerve-impulses 
from a part favors infection ; that the withdrawal of nerve-influence 
with partial failure of circulation in some cases of injury still further 
favors infection ; that there is a condition of traumatic nerve-irritation 
which, pi'obably by its abnormal influence on nutrition, favors infection. 
A partial injury of a nerve sets up local neuritis and may bring on ulcers 
of a peculiar character.' It seems to me that if we injure a nerve-supply, 
the changes in muscular and nerve conditions which immediately take 
place would favor such chemical changes in the tissues as to make them 
more or less susceptible to infection." 

Abnormalities in the secretions on exposed mucous surfaces and in 

' Interesting examples of such ulcers are here cited by Dr. Mitchell from the forth- 
coming book of his son, Dr. John H. Mitchell, on Nene-injuries and their Remote Resvlfs. 



CONDITIONS FAVORING THE DEVELOPMENT OF INFECTIONS. 297 

the glands communicating with them may be a local predisposing cause 
of infection. Obstruction to the outflow of secretions, and the presence 
of calculi or foreign bodies in cavities or glandular ducts opening upon 
exposed surfaces are important predisposing causes of infection, as is 
exemplified by inflammations of the vermiform appendix, renal peh'is, 
urinary and gall-bladders, urethra, the biliary, pancreatic, and salivary 
ducts. 

In general, all traumatic and pathological lesions of exposed surfaces 
of the body, such as wounds, hemorrhages, necroses, waxy degeneration, 
inflammation, ulcers, stricture, strangulation, perforation, increase in 
greater or less degree the opportunities for the entrance, lodgement, 
and multiplication of pyogenic and other micro-organisms. 

A suppurating surface, however, offers considerable resistance to the 
growth and invasion into the body of most pathogenic bacteria. Pus is 
endowed with marked bactericidal properties, both in its corpuscular 
elements and its fluid constituents, and the opportunities for absorption 
from a suppurating surface are much less favorable than from a fresh 
wound. Sestini found that the bacilli of anthrax and of rabbit septicte- 
mia when applied to a suppurating wound of the rabbit's skin produced 
no infection, although they readily did so when introduced into a fresh 
wound. Tlie existence of suppuration, however, lowers the general 
resistance of the body to bacteria. 

The various lesions ^vhich interrupt the continuity and integrity of 
the exposed surfaces of the body become most dangerous channels of 
infection when the general resistance of the body to infectious agents is 
lowered, as in various infectious fevers and constitutional diseases. 

Experiments and clinical observations have been made with reference 
to the amount of damage to the intestinal coats which is requisite in 
order to permit the passage of bacteria from the intestinal canal into 
the peritoneal cavity. Most observers have found the fluid in the sac of 
a strangulated intestinal hernia free from bacteria in the great majority 
of cases. Garr6 found bacteria only once in eight cases ; Rovsing did 
not find them at all in five cases ; nor did Ziegler in five cases ; Tavel 
and Lanz obtained a positive result only twice in seventeen cases of in- 
testinal strangulation ; in two out of three omental strangulations they 
found bacteria ; Tietze found bacteria in four out of nine cases, with the 
possibility that in some of the four cases they were accidentally intro- 
duced from without. Sanguineous hernial fluids with bloody infiltration 
of the intestinal coats were observed without the presence of bacteria, and 
even the fluid in sacs containing necrotic intestine did not always contain 
bacteria. The presence of fibrinous peritonitis over strangulated intestine 
does not necessarily involve the presence of bacteria in the exudate, as 
this form of peritonitis may be caused by the absorption of the chemical 
products of bacteria from the intestine (chemical peritonitis). Definite 
relations between the condition of the intestine and the presence of bac- 
teria in the hernial sac were not observed. 

For some at present inexplicable reason Boenneeken found bacteria 
in the sacs of all of the eight strangulated hernias which he examined. 

Arndt has shown by experiments on rabbits that bacteria may pass 
through the strangulated intestinal wall without the existence of necrosis 
of the intestine, and when the condition of the intestine is such that it 



298 GENERAL BACTERIOLOGY OF SURGICAL INFECTIOSS. 

quickly returns to the normal state upon relief from the strangulation. 
The presence of bacteria in the hernial fluid does not necessarily involve 
the development of peritonitis. The conditions which permit bacteria to 
wander from the intestine through its wall into the peritoneal cavity 
have not as yet been made clear. Tietze has shown that the fluid from 
a hernial sac possesses marked bactericidal power over some intestinal 
bacteria.' 

The entrance of the colon bacillus into the circulation is usually, in 
our experience, associated with some lesion of the intestinal mucosa, 
although this is not invariably the case. Absorption of pathogenic bac- 
teria, particularly the pyogenic cocci, from the diseased intestinal mucosa 
is a fruitful source of various infections of internal parts, and many 
cases regarded as cryptogenetic septico-pysemia have this origin. 

The importance of accessory and predisposing causes of inflamma- 
tions due to bacteria is nowhere better illustrated than in the etiology of 
peritonitis, as has been set forth by Dr. Councilman on page 1 80. There 
are two principal classes of predisposing causes of peritonitis — namely, 
substances which damage the endothelial cells of the peritoneum, and 
solid, unabsorbable substances. 

Of especial importance to the surgeon is a knowledge of the local 
and general predisposing causes of the infection of wounds. The gen- 
eral predisposing factors we shall consider later. From what has already 
been said, it is apparent that while the surgeon should use every effort to 
keep bacteria out of a wound, he should refrain so far as possible from 
doing anything which interferes with the power of the fluids and cells to 
overcome invading micro-organisms. 

Among the local conditions ^ which have been found favorable to the 
growth in wounds of bacteria which otherwise might be disposed of by 
the tissues and animal fluids without harm may be mentioned strangu- 
lation of masses of tissue by ligatures ; the presence of foreign bodies, 
such as drainage-tubes and coarse ligatures ; interference with the cir- 
culation and absorption and the vitality of tissues resulting from undue 
pressure or tension ; dead spaces ; accumulation of the fluid and solid 
discharges from a wound, especially when associated with tension ; necro- 
sis and degeneration of tissues caused by the contact of strong chemical 
irritants. If it were within the power of the surgeon to keep bacteria 
entirely out of wounds or to destroy them without damage to the tissues 
after they enter, the conditions just mentioned could not by themselves 
alone cause infection, but this power he does not at present possess. The 
so-called aseptic wound of the surgeon is not usually aseptic in the 
bacteriological sense ; that is, free from bacteria. 

The following objections to the insertion of drainage-tubes into 
wounds have been elsewhere formulated by the writer : ^ First. They 

' For the literature and the most important experiments and observations thus far 
made upon the subject of bacteria in hernial sacs consult Tavel and Lanz, " Ueber die 
Aetiologie der Peritonitis," Mittheilunc/en aun Kliniken und med. Imtit. d. Schweiz, Basle 
and Leipzig, 1893 ; Arndt, " Ueb. d. Durchlassigkeit d. Darmwand eingeklemmter Briiche 
fiir Mikroorganismen," ibid., 1893; and Tietze, Arch.f. kiin. Chiriirfiii; Ed. 49. 

^The writer wishes to aci;nowledge his indebtedness to his colleague, Dr. AVilliam 
S. Halsted of the Johns Hopkins Hospital, for information and numerous suggestions as 
to the influence of many local and general causes predisposing to the infection of wounds. 

^ Welch, "Some Considerations concerning Antiseptic Surgery," I'he Mai-yland 
Medical Journal, Nov. 14, 1891. 



CONBITIOSS FAVORING THE DEVELOPMENT OF INFECTIONS. 299 

tend to remove bacteria which may get into a wound from the direct 
bactericidal influence of the cells and animal juices. Seoond. Bacteria 
may travel by continuous growth or in other ways down the sides of a 
drainage-tube, and so penetrate into a wound which they otherwise would 
not enter. We have repeatedly been able to demonstrate this mode of 
entrance into a wound of the white staphylococcus found so commonly 
in the epidermis. The danger of leaving any part of a drainage-tube 
exposed to the air is too evident to require mention. Third. The chang- 
ing of dressings necessitated by the presence of drainage-tubes increases 
in proportion to its frequency the chances of accidental infection. Fourth. 
The drainage-tube keeps asunder tissues which might otherwise imme- 
diately unite. Fifth. Its presence as a foreign body is an irritant and 
increases exudation. Sixth. The withdrawal of tubes left any consider- 
able time in wounds breaks up forming granulations, and thus both pro- 
longs the process of repair and opens the way for infection. Granulation 
tissue is an obstacle to the invasion of pathogenic bacteria from the sur- 
face, as has been proven by experiment. Seventh. After removal of the 
tube there is left a tract prone to suppurate and often slow in healing. 

The advantage from the employment of drainage-tubes or other drain- 
age material is, of course, the removal of secretions, and this indication 
becomes an urgent one if the cavity with which the tube communicates 
is infected and suppurates. In a given case the surgeon must weigh the 
advantages and the disadvantages and act according to his judgment. 
The practice of most surgeons at the present time of restricting within 
much narrower limits than formerly the use of drainage-tubes, and of 
discarding them for all wounds which oiier a fair prospect of primary 
union, is a distinct advance in the technique of antiseptic surgery. 

The presence of blood in a wound is not itself to be desired, and 
modern surgeons justly lay stress upon prompt and careful hsemostasis 
in surgical operations. Blood in a wound is not, however, so dangerous 
a thing as some have supposed it to be, and where for the obliteration 
of cavities in a wound the choice lies between a blood-clot and the intro- 
duction of foreign substances, or the exercise of undue tension by sutures, 
or the application of a very large number of sutures, or forcible pres- 
sure, it is, as a rule, better to take the chances that the spaces will fill 
with blood (Halsted). Blood possesses bactericidal properties, and experi- 
ments made by the writer and Howard ' showed that virulent pyogenic 
staphylococci injected into blood-clots which had been allowed to fill 
wound-cavities did not multiply and occasioned no suppuration. John 
Hunter was fond of dwelling upon what he called the vitality of blood, 
and John Chiene has directed attention anew to similar views. Schede 
brought prominently to the notice of surgeons the value of the blood-clot 
in the healing of a certain class of wounds, and Halsted '^ further extended 
the field of its application. The unintended presence of blood in a wound 
by occasioning undue tension and in other ways may be a dangerous 
thing, and is something very different from the purposeful application of 

' Welch, " Conditions underlying the Infection of Wounds," Transactions of the 
Second Congress of American Physicians and Surgeons, vol. ii., 1891. 

^ Halsted, " The Treatment of Wonnds with especial reference to the Value of the 
Blood-clot in the Management of Dead Spaces," The Johns Hopkins Hospital Report's, vol. 
ii. No. 5. 



300 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

the method of healing by so-called organization of blood-coagula. It is 
of the first importance to prevent so far as possible all tension in a 
wound. 

Undue stress is sometimes laid upon artificial devices to close the so- 
called dead spaces of a wound. These spaces when not drained, nor 
stuffed with foreign substances, nor obliterated by sutures or pressure, 
nor permitted to fill with blood, do not, unless very large, remain empty 
spaces. They quickly fill with exudations of fluids and cells, and these 
fluids and cells possess antibacterial properties as well as blood. For 
cavities with unyielding walls, such as those in bone, the blood-clot 
method of treatment has been found especially useful.^ 

Surgeons are not agreed as to the value of the application of antiseptic 
fluids and substances to fresh wounds. There has been in recent years, 
under the name of aseptic surgery, a general tendency to consider them 
useless or harmful, but some surgeons still advocate the antiseptic irri- 
gation of fresh wounds. The question is one which can be decided only 
by clinical experience. The experimental data bearing upon the ques- 
tion are the only ones appropriate to consider here. 

The principal objections urged against the employment of the appli- 
cation of such disinfectants as corrosive sublimate and carbolic acid to 
fresh wounds are — first, that tliey accomplish little or nothing in the way 
of destroying bacteria which may have entered the wound ; and, second, 
that they cause necrosis or other impairment of the tissues, and thereby 
weaken or abolish the antibacterial properties of the tissues, and thus 
predispose to infection. 

The conditions for the destruction of baoceria by chemical disinfect- 
ants in the fluids and tissues of the animal body, even when the bacteria 
are only upon an exposed surface, are most unfavorable as compared 
with those in experiments Avith the same agents in test-tubes. The 
experiments of Schimmelbusch, already cited, do not, as he seems to 
suppose, demonstrate the uselessness of antiseptic applications to wounds 
in general. He found that the fatal infection of mice with the bacillus 
anthracis and that of rabbits with the bacilli of rabbit septicaemia, intro- 
duced in large number into fresh wounds, could not be prevented by the 
irrigation of the wound with corrosive sublimate (1 : 1000) or carbolic 
acid (5 per cent.) or other antiseptics. But some of the bacteria thus 
introduced, as has already been explained, are immiediately or very soon 
absorbed from fresh wounds, and if one bacillus or a very few bacilli of 
the kind used by Schimmelbusch were thus absorbed, the death of the 
animal was sure to follow ; whereas a similar absorption of a few ordinary 
pyogenic cocci is usually without significance. It is evident that these 
experiments are not conclusive as to the influence of antiseptics upon 
bacteria which remain in the wound, and are not applicable to the ordi- 
nary conditions of wound-infection during a surgical operation. 

Henle ' in his experiments conformed more closely to conditions of 
wound-infection in man. He found that in wounds of the rabbit's ear 
inoculated with streptococcus pus the streptococci remained in the wound 
for six hours, after Avhich the cocci began to occupy the neighboring 
lymph-spaces. He found that regularly up to the end of the second 
hour a complete disinfection of the wound with sublimate (1 : 1000) or 
' Henle, Centralblatt fur Chirurgie, 1894, No. 30, Beilage. 



CONDITIONS FAVORING THE DEVELOPMENT OF INFECTIONS. 301 

carbolic acid (4 per cent.) could be attained, and that even after six hours 
the disinfection sometimes prevented tlie development of the disease, and, 
if not completely successful, rendered the subsequent infection milder than 
in the inoculated control ear which was not disinfected. 

Loffler has shown by his careful tests of the action of various anti- 
septic substances upon diphtheritic throats that it is possible to destroy 
the superficial bacteria by antiseptics without serious injury to the tissues. 
It is possible that disinfectants, without actually killing bacteria, may 
restrain their power of development or weaken their virulence. 

Messner' experimented by inoculating fresh wounds of I'abbits with 
pus or with cultures containing pyogenic cocci, which caused progressive 
phlegmonous inflammation with fatal termination. He found that, with 
one exception, all of the ten wounds inoculated with the cocci, and then 
irrigated with sterile salt-solution and treated aseptically, suppurated, 
with the development of progressive phlegmons which killed the animal 
within two weeks. On the other hand, all of the ten wounds, with one 
exception, similarly inoculated and treated antiseptically with lysol or 
3 per cent, carbolic-acid solution, healed and the animals survived. Two 
of the wounds treated antiseptically healed without suppuration ; the 
remaining eight suppurated, showing that the cocci had not actually 
been destroyed, but the process remained localized. Pus from the 
wounds treated aseptically preserved its virulence, whereas pus from the 
wounds treated antiseptically was devoid of virulence when inoculated 
into animals. 

Hermann and others have shown that if carbolic acid, corrosive sub- 
limate, and various other chemical irritants be injected subcutaneously 
into the tissues and soon afterward pyogenic micro-organisms be injected 
into the same locality, the formation of an abscess is much more likely 
to follow than when the bacteria are injected into the healthy tissues. 
But, as Messner has shown, a similar favoring influence upon the devel- 
opment of suppuration under these circumstances is exerted by the injec- 
tion of common salt-solution into the subcutaneous tissues. These exper- 
iments are not applicable to the conditions existing in an open wound, 
but they confirm clinical observations as to the great danger of intro- 
ducing into the subcutaneous tissues of man, with a hypodermic syringe, 
fluids containing pyogenic bacteria. 

Unquestionably, the presence of necroses, such as may be produced 
by strong chemical disinfectants, predisposes to pyogenic infection. In 
some situations, as in a closed cavity like the peritoneal, the presence of 
even superficial necroses, which may affect only the endothelial cells, is 
an important predisposing cause of infection, but only experience can 
decide whether such slight superficial necrosis or other injury which the 
ordinary antiseptics may produce in an external wound is in itself an 
important predisposing factor in the pyogenic infection of ^^'Ounds, or 
even if a predisposing factor is not more than counterbalanced by bene- 
ficial influences exerted by the application of antiseptics. Messner has 
reported experiments on rabbits which seem to show that the irrigation 
of fresh wounds with 3 per cent, carbolic-acid solution does not lessen 
the vital resistance of the tissues in a wound to subsequent inoculation 
with pyogenic cocci. 

' Messner, Ibid. 



302 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

Experiments upon animals, therefore, favor rather than oppose the 
antiseptic treatment of wounds, as distinguished from so-called asepsis. 

, We turn now to the consideration of local predisposition existing at 
some point within the body, the so-called locus minoris resistentise. After 
the infectious agents have passed through the portal of entry and entered 
the general circulation they may find local conditions favoring their lodge- 
ment and development. Without such local predisposition they are often 
incapable of doing any harm. 

Injury, inflammation, and other pre-existing disease of an internal 
part are important and common conditions favoring the lodgement and 
growth of micro-organisms. The classical experiment of Chauveau many 
years ago demonstrated the predisposition of injured internal parts to 
infection. He twisted oif without rupture of the skin one of the testicles 
of a young ram from its vascular connections (bistournage), and observed 
that when he had injected shortly before the operation putrid fluid con- 
taining micro-organisms directly into the circulation the injured testicle 
became tlie seat of septic gangrene, while without such injection the tes- 
ticle became necrotic and was absorbed without becoming infected. 

The experiments of Eosenbach, Orth and Wyssokowitch, Prudden, 
and others have shown that bacteria do not readily become attached to 
the smooth surface of the heart-valves, but that pyogenic cocci readily 
adhere and set up septic endocarditis when the valves have been pre- 
viously torn by a sterile probe passed down the carotid artery. The 
predisposition of injured joints and bones to the settlement of pyogenic 
cocci and of tubercle bacilli is established both by clinical and exper- 
imental observations. Pyogenic cocci often invade foci of disease caused 
primarily by other organisms, as is exemplified in tuberculous and gonor- 
rhceal arthritis, actinomycosis, echinococcus cysts, amoebic abscesses of 
the liver, etc. In some situations, particularly in the kidney and urinary 
tract, the colon bacillus often settles in pre-existing foci of disease. The 
ansemic and dry condition of the lung induced by pulmonary stenosis 
favors the development of pulmonary tuberculosis. The hypersemic and 
moist condition associated with mitral regurgitation is comparatively 
unfavorable to such development, although by no means excluding this 
disease. Pyogenic cocci not infrequently settle in the joint-lesions of 
locomotor ataxia and cause suppuration. 

The existence of a diseased or injured part within the body by no 
means involves, of necessity, the localization therein of infectious pro- 
cesses which may be caused by pathogenic micro-organisms in the circu- 
lation. The damaged part may be spared and an apparently healthy 
part attacked. The endeavor to obtain experimentally in animals the 
localization of suppuration in a fractured bone or other injured or dis- 
eased part by pyogenic cocci injected into the circulation often fails, and 
in the hands of Rinne failed so regularly that he opposes, although 
without sufficient reason, the whole doctrine of locus minoris resistentise. 
By a different line of experimentation Gottstein came to the same con- 
clusion as Rinne. 

_We are undoubtedly able in some cases to explain the localization of 
an infection by such apparent local predisposing causes as those which 
have been mentioned, but in many, indeed in the majority of, instances 
of localized infections of internal parts we are unable to give any satis- 



CONDITIONS FAVORING THE DEVELOPMENT OF INFECTIONS. 303 

factory explanation of the localization. We know that many patho- 
genic micro-organisms have a decided preference for certain organs and 
tissues. The injection of the staphylococcus aureus into the circulation 
of rabbits does not lead to the formation of abscesses in all parts of the 
body, although the cocci must be carried by the blood-current every- 
where. The abscesses are found most frequently in the kidneys and 
myocardium, sometimes in the muscles elsewhere, and in young rabbits 
often in the bone-marrow and joints. To say that the tissues in one 
part of the body offer better conditions for the growth of the micro- 
organisms than in other parts is only another way of saying that the 
organisms produce disease in one part and not in another. Such phrases 
offer no real explanation unless the nature of these better conditions can 
be defined. 

Sometimes we can explain the localization by the manner of recep- 
tion of the virus, the vascular relation of the part to infected areas, the 
size and number of the capillaries, the velocity of the circulation, and 
the readiness with which foreign particles are filtered out. We know 
that fine particles are deposited from the lymphatic current in the lymph- 
glands, and from the blood-circulation chiefly in the spleen, marrow of 
the bones, liver, and lymph-glands. More often we are unable to give 
any adequate explanation of the localization of an infectious process in 
internal parts of the body. 

Gexeral Predisposition. — Under this heading we shall consider 
predisposing causes which act more or less generally upon the whole 
body. The effect of such causes may be to increase the susceptibility 
of the whole body or only of particular parts of the body to infection. 
The factors here concerned are for the most part less tangible than the 
local causes of predisposition. 

Organs and parts of the body may inherit special vulnerability to 
certain infections. Susceptibility to certain infectious diseases may be 
manifest in races and families. The negro race is less susceptible to 
yellow fever than the white. Algerian sheep are in large measure insus- 
ceptible to anthrax, which is very fatal to other sheep. Black rats are 
more resistant than gray, and gray rats more resistant than white, to 
anthrax (Miiller). 

Age influences predisposition, as regards some infectious diseases favor- 
ably, as regards others unfavorably. W^ounds in children, as a rule, 
heal more quickly, and with less danger of suppuration should pyogenic 
bacteria enter, than in old people. Certain infectious diseases are most 
common in infancy, others in adolescence or in maturity or in old age. 
Osteomyelitis is much more common in children than in adults. This 
has been attributed to the predisposing influence of injuries to which 
children are more liable. Doubtless inJTiries enter into the causation as 
a predisposing factor, but it has been shown experimentally that there is 
a special susceptibility of the bone-marrow of young growing animals to 
infection by pyogenic cocci injected into the circulation (Rodet, Colzi, 
Courmont and Jaboulay, Lannelongue and Achard, Lexer). In labora- 
tory experiments young animals, as a rule, are found to be more suscept- 
ible to most pathogenic bacteria than old ones. There is a special insus- 
ceptibility of sucklings during the first months of life to certain infectious 
diseases, such as mumps, measles, scarlet fever. As will be explained 



304 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 

later, the embryo possesses remarkable insusceptibility to some infec- 
tions. 

There is no evidence that there is any difference in predisposition to 
infection between males and females, except as regards infections directly 
related to sexual functions. 

General anaemia, induced by loss of blood, has been shown experi- 
mentally to increase susceptibility to infection with various micro-organ- 
isms, including the pyogenic cocci, Friedlander's bacillus, and the an- 
thrax bacillus (Rodet, Gartner, Chauveau, and others). Operative and 
other wounds are more likely to suppurate when there has been much 
hemorrhage than when the loss of blood is slight. In general, impaired 
vitality and nutrition of the body may predispose to certain infections, 
including wound-infection. More or less plausible predisposing causes 
operating in this way are bad and insufficient food, overwork, depressing 
emotions, exposure to heat or cold, overcrowding, bad air, and, in general, 
insanitary surroundings and all conditions of misery. 

A large number of experiments have been made upon animals to 
determine the influence of various factors in increasing susceptibility to 
infection. The results of these experiments are interesting and suggest- 
ive in many ways. Some of them evidently correspond to conditions 
observed in man, but it is to be remembered that without additional evi- 
dence we have no right to apply the results directly to human beings, or 
to any other bacteria or other animals than those experimented with. 
The more important results of these animal experiments are the fol- 
lowing : 

Prolonged narcosis may impair resistance to some pathogenic micro- 
organisms. Klein and Coxwell made frogs and rats highly susceptible 
to anthrax by narcosis with ether and chloroform, and similar results